Vasectomy Self-Referral Form

Vasectomy Self-Referral Form
Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NHS Number*
NHS number is mandatory https://www.nhs.uk/find-nhs-number/what-is-your-name
Date of Birth*

DayMonthYear
Date
Next of Kin & Contact Number
Are you Armed Forces Personnel?

YesNo
Current Job
Registered GP Practice*
If you cannot find your GP Practice in this list you may be outside of our contracted area. Please email us on midhantshc.vasectomyservice@nhs.net to enquire further.
Length of current relationship (YY/MM)
If your partner is pregnant what is the estimated due date

MonthDayYear
Date
List Children (ages) from current relationship
List Children (ages) from previous relationships
Medical History
Do you have Diabetes?

YesNo
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?

YesNo
If Yes, please provide details
Are you on any anti-coagulant/platelet medication?

YesNo
If yes, please provide details
Are you immunosuppressed or on immunosuppressant medication?

YesNo
If yes, please provide details
Height
Weight
Have you had a previous allergy to Local Anaesthetic?

YesNo
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

Clear
Should be Empty:

Vasectomy Self-Referral Form

Medical History

I confirm that I have read the Patient Information Brochure and understand the following: