Private 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
*
NHS number is mandatory https://www.nhs.uk/find-nhs-number/what-is-your-name
Date of Birth
*
-
Day
-
Month
Year
Date
Next of Kin & Contact Number
Current Job
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
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
*
Submit
Should be Empty: