VASECTOMY
Version 06.08.23
Name
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
1. How many biological children do you have?
*
0
1
2
3
4
5
2. What are the ages of your current children? (list youngest to oldest)
*
3. How many biological children does your current partner have?
*
0
1
2
3
4
5
4. What are the ages of the children of your current partner?
*
5. What is the age of your current partner?
*
6. How many children have you and your current partner had together?
*
0
1
2
3
4
5
7. Who was most influential in deciding to get your vasectomy?
*
You
Your partner
Equally you and your partner
Someone else (please specify)
Patient or Representative Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: