Pre Vasectomy Counselling Information Gathering Form

Please Complete this form prior to your Pre Vasectomy Call with Dr Richard
Name

First NameLast Name
Date of Birth*

DayMonthYear
Date
Address

Street Address

Street Address Line 2

CityCounty

Eircode
Email
example@example.com
Your Occupation
Optional
Mobile Phone Number
Please enter a valid Mobile phone number.
Your CONFIRMED and scheduled procedure date

DayMonthYear
Only complete this date if you have already booked a date via the app or telephone
I confirm that I have read the 'Having a Vasectomy' Booklet

YesNoI did not receive it
Your Current Contraceptive ?

Contraceptive pillCoilImplantCondomsNo Contraceptives used
Number of Children
Age of your youngest child
Have you ever had surgery on your tummy (eg appendix or hernia repair) or testicles*
Please give details
Have you had 2 vaccinations against COVID 19

YesNo
Do you take any medication that could affect blood clotting (eg Aspirin, Warfarin, Heparin, NOACs)
Do you have any allergies to medication
Have you ever been treated for Mental Health disorders (Depression, Anxiety, Sexual dysfunction)

YesNORather not say
Please list any medication that you are currently taking
I understand that this is a permanent procedure and not intended to be reversed. Sterility is not guaranteed
Do you require a pre vasectomy call ? Yes/NO

YesNo
Please ask any specific questions to cover during your Pre Op Call
Where did you hear about us?

Google Ads SearchWord of mouthGoogle reviewsMy GPOther
Reception will book your Pre Vasectomy Call for the week before your procedure

Please check your confirmation letter for the date and time
PLEASE PERFORM A COVID ANTIGEN TEST ON THE MORNING OF YOUR PROCEDURE. Please see the following video on how to antigen test How to do an antigen test
Should be Empty:

Please Complete this form prior to your Pre Vasectomy Call with Dr Richard

Reception will book your Pre Vasectomy Call for the week before your procedure