Vasectomy Self-Referral Form
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
NHS Number
Date of Birth
*
-
Day
-
Month
Year
Date
Next of Kin & Contact Number
Are you Armed Forces Personnel?
Yes
No
Current Job
Registered GP Practice
Please Select
Abbeywell Surgery
Adelaide Medical Centre
Aldermoor Health Centre
ALDERSHOT MEDICAL CENTRE
Alma Road
Alma Road Surgery
Alresford Surgery
Archers Practice (Eastleigh Health Centre)
Argyll House
Atherley House Surgery
Badgerswood Surgery
Bishops Waltham Surgery
Blackthorn Health Centre
Blossom Health Practice
BORDON MEDICAL CENTRE
Bosmere Medical Practice
Boundaries Surgery
Boyatt Wood Surgery
Bramblys Grange Medical Practice
Bridgemary Medical Centre
Brook House Surgery
Brook Lane Surgery
Burgess Road Surgery
Camrose Gillies and Hackwood Partnership
Centre Practice
Charlton Hill Surgery
Chawton House Surgery
Chawton Park Surgery
Cheviot Road
Chineham Medical Practice
Clift Surgery
Coastal Medical Partnership
(Arnewood Practice, Barton Surgery and Webb People Surgery, New Milton Health Centre)
COLLINGWOOD MEDICAL CENTRE
Cornerways Medical Centre
Cowes Medical Centre
Craneswater Group Practice
Crown Heights Medical Centre
Derby Road Surgery
Drayton Surgery
East Cowes Medical Centre
East shore Partnership - Baffins
Elms Practice
Emsworth Medical Practice
Esplanade
EXCELLENT MEDICAL CENTRE
Fordingbridge Surgery
Forestside Medical Practice
Friarsgate Practice
Fryern Surgery
Grange Surgery
Gratton Surgery
Gudgeheath Lane Surgery
Hedge End Medical Centre
Highfield Health
Hill Lane Surgery
Homeless Healthcare
Homewell Practice
Horndean Surgery
Island City Practice
KEOGH MEDICAL CENTRE
Kirklands Surgery
Lighthouse Group - Southsea branch
Living Well Partnership
Lockswood Surgery
Lordshill Health Centre
Lyndhurst Surgery
MARCHWOOD MEDICAL CENTRE
Medina Healthcare
Meon Health Practice
MIDDLE WALLOP MEDICAL CENTRE
Mulberry Surgery
NELSON MEDICAL CENTRE
New Forest Medical Group
New Horizons Medical Partnership
Newport Health Centre
North Baddesley Health Centre
Oaks HealthCare
Odiham Health Centre
ODIHAM MEDICAL CENTRE
Park Surgery and St Francis
Parkside Family Practice (Eastleigh Health Centre)
Peartree Practice
Pinehill Surgery
Portchester Health Centre
Portsdown Group Practice - Kingston Crescent
PORTSMOUTH MEDICAL CENTRE
Raymond Road
Red and Green Practice
Ringwood Medical Centre
Rowlands Castle Surgery
Rowner Surgery
RRU ALDERSHOT
RRU PORTSMOUTH
RRU TIDWORTH
Shakespeare Road Medical Practice
Shepherds Spring Medical Centre
Shirley Health Partnership
Solent GP
Solent View Medical Practice
South Wight Medical Centre
SOUTHWICK PARK MEDICAL CENTRE
St Andrew's Surgery
St Clements Partnership
St Helen's
St Mary's Surgery
St Mary's Surgery
St Paul's Surgery
St Peters Surgery
Stockbridge Surgery
Stokewood Surgery
Stoneham Lane Surgery
Stubbington Medical Practice
SULTAN MEDICAL CENTRE
Swan Medical Group
Tadley Medical Partnership
Testvale Surgery
The Andover Health Centre Medical Practice
The Bay (Sandown & Shanklin)
The Clanfield Practice
The Denmead Practice
The Old Fire Station
The Watercress Medical Group
THORNEY ISLAND MEDICAL CENTRE
TIDWORTH MEDICAL CENTRE
Tower House
Trafalgar Medical Group Practice
Twin Oaks Medical Centre
Twyford Surgery
Uni-City medical centre
University Health Centre
Ventnor
Victor Street Surgery
Village Practice
Vine Medical Group
Walnut Tree Surgery
Waterfront and Solent Surgery
Watership Down Health
Waterside Medical Practice
West End Road
West Meon Surgery
West Wight
Westlands Medical Centre
Whitchurch Surgery
Whitewater Surgery
Wickham Surgery
Willow Group
Wilson Practice
WINCHESTER MEDICAL CENTRE
Wistaria and Milford Surgeries
Woolston & Chartwell Partnership
WORTHY DOWN MEDICAL CENTRE
Length of current relationship (YY/MM)
If your partner is pregnant what is the estimated due date
-
Month
-
Day
Year
Date
List Children (ages) from current relationship
List Children (ages) from previous relationships
Medical History
Do you have Diabetes?
Yes
No
What medication do you take for Diabetes?
Please enter your most recent Hb1AC result and the date of test
*Diabetics must have had a Hb1AC within the last 6 months with a result of less than 69mml
Previous operations/problem with scrotum/testes?
Yes
No
If Yes, please provide details
Are you on any anti-coagulant/platelet medication?
Yes
No
If yes, please provide details
Are you immunosuppressed or on immunosuppressant medication?
Yes
No
If yes, please provide details
Height
Weight
Have you had a previous allergy to Local Anaesthetic?
Yes
No
If yes, please provide details
Please list all current medication
Please detail any drug allergies: name of drug and what reaction was experienced
Please list past medical history and/or Long Term Conditions
I confirm that I have read the Patient Information Brochure and understand the following:
(you must confirm all statements)
*
Signature
Submit
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