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
Please detail any additional assistance you require during your phone assessment or clinical appointment
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: