Vasectomy Questionnaire

We invite you to answer a few questions in order to ensure that you are happy to proceed. If all of your answers indicate that you are happy to proceed, we will refer you for the procedure.

Vasectomy Questionnaire

Vasectomy Questionnaire

Before completing this questionnaire, please read our Vasectomy Information Leaflet.

*

Patient Details

Please use date format DD/MM/YYYY
Any responses will be sent to this email address.

Vasectomy Questionnaire

I can confirm that I have read and understood all of the information given above *
I understand that a vasectomy should be considered to be an irreversible procedure and that if a reversal is requested this will not necessarily be successful and is unlikely to be available on the NHS *
I understand the risks associated with the procedure listed above including, but not limited to, the fact that up to 5% of men have long-term pain after the procedure and that the procedure has a failure rate of 1 in 2000 *
Do you have any further questions about the procedure that you feel have not been covered above? *
Taking all of the above in to account, would you like The Westgate Practice to refer you to the local Vasectomy Clinic? *