Private Vasectomy Self-Referral Form
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Format: 00000000000.
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
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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
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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:
Please confirm that you have read and understood all seven statements below (all must be ticked)
*
I agree to the Terms & Conditions and associated fees relating to MHH Private Vasectomy as published on the MHH website.
The procedure is irreversible on the NHS.
The failure rate is 1:100 immediate and 1:2000 late.
There is a risk of Chronic Post Vasectomy Pain.
I am aware of the availability of LARC (Long Acting Reversible Contraception) as an alternative method of contraception.
I am aware that some men will later regret having a vasectomy.
By completing this form I consent to MHH accessing my medical records.
Signature
*
Date of Signature
-
Day
-
Month
Year
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Submit
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