• South Sound Vasectomy

    Intake Form
  • Date of birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What is your preferred method of communication?

  • Insurance Information

  • Will you be using insurance?*
  • Is this Tricare?
  • Do you have secondary insurance?*

  • Health Information

  • Level of exertion at work?*
  • Do you take any medications?*
  • Do you have any medication Allergies?*
  • Do you have any medical problems?*
  • Have you ever had any of the following surgeries?*

  • Do you have or have you haver had:*
  • Do you use tobacco?*
  • Do you drink alcohol?*
  • Do you have a primary care doctor?*
  • Format: (000) 000-0000.
  • Do we have your permission to send a copy of your vasectomy report to your primary care doctor so that their records will be complete?*

  • Family Information

  • Relationship Status:*
  • Your partner's permission is not required for vasectomy; however, are they aware that you are having one?*
  • May we communicate with your partner regarding vasectomy care, scheduling, and post vasectomy semen checks?*
  • Were all of your children Planned?
  • Was your youngest child planned?
  • Is your partner currently pregnant?*
  • What is your current method of birth control?
  • What is your current method of birth control?

  • Confirmation and Attestation Page

  • Please review the below pre-vasectomy instructions.

    Pre-vasectomy Instructions

  • Please review the below post-vasectomy instructions.

    Post-vasectomy Instructions

  • Please review the below privacy policy.

    SSV HIPAA form

  • Please review the below financial policy.

    SSV financial form

  • Communication Preferences

    We do not sell or use your contact information for marketing.

  • Knowing that the below forms of communication are not always private or secure...

  • Can this office communicate with you by phone?*
  • Can this office leave a voice message at the phone number you provided?*
  • Can this office communicate with you by text?*
  • Can this office communicate with you by email?*
  • How did you hear about us?

  • If you have not already scheduled an appointment, you will hear back from us within 3 buisness days of submitting this form to schedule an appointment that is convenient for you.

  • Should be Empty: