Vasectomy Consent Form – Aussie Vasectomy Care

Patient Name

First Name/sLast Name
Preferred Name
If Different
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Age
Email
Mobile Number
Address

Street Address

City / SuburbState

PostcodeCountry
Emergency Contact
Name
Emergency Phone Number
Medicare details (for your rebate). Please ensure name on this form matches your name on the card

Medicare card numberReference (number before your name)Medicare expiry
GP Name
GP Clinic
I consent to Aussie Vasectomy Care informing my GP about my procedure
Number of children (if any)
Current Contraception
Medical History
Do you have any medical conditions? Please list them
Medications
Do you have any regular medications? Please list them
Do you have any drug allergies?
If yes, list drugs you are allergic to
Have you had scrotal surgery or scrotal issues?
If YES, please specify
For example surgery for torsion, undescended testicle, trauma, cysts, varicocoele, testicular cancer, chronic pain, epididymitis?
Have you ever fainted or felt light-headed during a medical procedure or blood test?
If YES please give details
To help reduce the chance of fainting, we recommend drinking plenty of fluids and having a light meal before your appointment. There is no need to fast.
What is your occupation?
Do you require a medical certificate for day/s off work? If yes, please specify dates. Medical certificates make no mention of vasectomy
If your work involve manual labour we can provide a certificate for up to 2 weeks.
If you require a certificate for light duties or a carer's certificate please specify dates and carers name
If your work involve manual labour or heavy lifting we recommend light duties for a week or some time off.
How did you hear about Aussie Vasectomy Care?
About the Procedure
A vasectomy is a highly effective, permanent form of contraception.

It works by dividing the vas deferens, the tubes that carry sperm from the testicles. After the procedure, semen is still produced, but it should no longer contain sperm once clearance has been confirmed by semen testing.

Vasectomy should be regarded as permanent. Although reversal may sometimes be possible, it is expensive, not guaranteed to work, and should not be relied on.
Vasectomy Patient Consent Form
If you have not yet watched Dr Marcel Kalau’s preparation video, please do so before completing this form. A link was sent via SMS and email when you booked. It can also be viewed here: https://www.youtube.com/watch?v=VFtmJJmb1eM If you cannot access the video, please contact us.
To help your procedure run smoothly, please shave your scrotum the night before or the morning of the procedure, using the shaving guide
On the Day
- Eat and drink normally (no fasting required)
- Wear supportive underwear
- Procedure takes 15 - 20 minutes, with time also allowed for questions and follow up
- Performed under local anaesthetic (you will be awake)
- Modern no-scalpel technique
- We prefer you not to drive yourself home, however if you must drive you are required to wait at least 30 minutes before driving. You must not drive if you feel dizzy or light-headed.
After the Procedure
- Use ice packs and simple pain relief as needed
- Avoid heavy lifting, exercise and sexual activity for 1 week
- Avoid cycling and contact sports for 3 weeks
- You must continue using contraception until your semen test confirms clearance
- This test is done around 12 weeks after the procedure
- Until then, you should consider yourself fertile
Risks and Possible Complications

Vasectomy is a very safe procedure, but all procedures carry risks. The vast majority of men recover without any complications.
Common and Expected
- Mild discomfort
- Mild bruising
- Mild swelling
Less Common but Important
- Fainting or light-headedness during the procedure. (around 1 in 100) Some men may briefly faint or feel light-headed, similar to a blood test or injection. This usually settles quickly.
- Infection. (around 1 in 100) or (≤1%). This may cause redness, swelling, discharge, pain, or fever, and usually requires antibiotics
- Bleeding or haematoma (up to 1 in 100) or (≤1%). Bleeding into the scrotum can cause swelling and discomfort. Small haematomas often settle without treatment, but rarely drainage or surgery may be required
Rare Risks
- Failure of the procedure / early recanalisation. In rare cases, sperm may continue to be present after vasectomy and a repeat procedure may be required (around 1 in 1000)
- Delayed recanalisation. Very rarely, the vas deferens may rejoin after a man has previously been told he is clear (around 1 in 2000 to 1 in 3000)
- Sperm granuloma. A small lump of scar tissue may form near the vas. This is usually minor and often settles over time (uncommon, usually minor)
- Congestive epididymitis / epididymal discomfort. Some men may experience aching or pressure from sperm build-up after the procedure. This is usually temporary and often improves with anti-inflammatory medication (uncommon, usually temporary)
- Post-vasectomy pain syndrome. Very occasionally, pain may persist for more than 3 months. This is usually manageable with medication, but rarely further treatment or surgery may be needed (around 1 in 1,000 to 1 in 2,000)
Consent

By signing below, I confirm that:
- I understand what a vasectomy is and that it is intended to be a permanent form of contraception
- I understand the alternative options available to me, including other forms of contraception or not proceeding with vasectomy
- I confirm that I am making this decision voluntarily and am not being pressured or coerced. I can change my mind at any time before the procedure and will not be charged.
- I understand that vasectomy is not immediately effective and that I must continue to use alternative contraception until I have been formally advised that my semen test confirms clearance
- I understand the risks, possible complications, and limitations of vasectomy
- I understand that vasectomy is highly effective but not 100% reliable, and that there is a small risk of failure or recanalisation which may result in ongoing fertility
- I consent to the vasectomy procedure being performed under local anaesthetic, including routine medications if required
- I consent to emergency treatment being provided if required
- I understand that in extremely rare circumstances possible complications of a vasectomy could lead to loss of a testicle
- I understand that if the procedure cannot be completed safely, or if complications occur, I may require referral to a specialist and additional fees may apply
- I understand the fees relating to my care and provide informed financial consent
- I understand that semen testing is performed externally and may involve additional fees
- I assign my Medicare benefit to Dr Marcel Kalau for any Medicare bulk-billed service provided as part of my vasectomy care. Where applicable, this may include MBS item numbers 23, 36, 18262, 37623, 91891, 92734, 75870, 75871, 10990 and 10991. I understand that by assigning my Medicare benefit, these services will be accepted as full payment and I will not incur any out-of-pocket fee for any bulk-billed service.
- I consent to receiving results and other relevant communication via SMS and/or email
- I confirm that I have read and understood the information provided and have had the opportunity to ask questions before making this decision
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Patient Signature
Should be Empty:

About the Procedure

Vasectomy Patient Consent Form

On the Day

After the Procedure

Risks and Possible Complications

Consent