PLEASE PRINT IN BLOCK LETTERS

Surname_____________________________ Forename______________________________

Address____________________________________________________________________

____________________________________ Postcode _____________________________

Day Phone No________________________ Occupation ___________________________

Your doctor's name and address_____________________________________________

___________________________________________________________________________

May we contact your doctor? (please tick) Yes No

Your D.O.B_______ Partners age_______ Length of present relationship_______

Age and sex of children you have fathered__________________________________

___________________________________________________________________________

MEDICAL HISTORY

Please tick if you have had any of the following:

Surgery for undescended testicle (at any age)_____ Jaundice/hepatitis______

Other testicular surgery___________________________ Allergies______________

Hernia repair__________________________ other serious illness______________

Further details (if yes to any of the above)_______________________________

PRESENT METHOD OF BIRTH CONTROL (please tick)

Sheath______ Pill______ Coil______ Cap______ Other______________ None______

After vasectomy you must use a method of birth control until you have been notified the operation has been success after satisfactory semen tests. Which will you use?

Sheath______ Pill______ Coil______ Cap______ Other______________

CONSENT

Please read carefully before signing

I have read the accompanying information on vasectomy:

Fully understand that the nature and purpose of male sterilisation (vasectomy) is to make me sterile and incapable of fathering a child:

Am aware that it may not be possible to reverse this operation:

Understand that no assurance has been given that will be 100% safe or successful:

Consent to the operation under local anaesthetic.

Signed____________________ Date____________________

To be signed by your partner (not compulsory)

I understand that the nature and purpose of the operation is to make my partner sterile and that it may not be possible to reverse it. I have read this form and agree to him have a vasectomy.

Signed____________________ Date____________________