Vasectomy Booking Form

Name on BC Medical Card: *

Date of Birth / Day - Month - Year *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Address: *

City *

Postal Code *

Phone Number *

Email *

Medical Care Card # *

Referred by Doctor (Name). - You MUST have a referral from your family doctor or a walk in / virtual clinic *

Doctor's Phone Number *

Your Age *

Marital Status *

• Yes, I have a partner
• I am not married

Age of partner *

Number of years together *

If any children, how many children do you have? *

Your Height : *

and *

Your Weight *

Current Birth Control Method : *

Regular medications ( including Aspirin and any over the counter medications ) : *

Allergies to medications : *

Health Questions :

Do you have diabetes? *

• Yes
• No

Have you ever had ANY surgery on your scrotum, including any operations as a child, repair of an undescended testicle, or testicular torsion, or a groin hernia repair? *

• Yes
• No

if yes, what kind of surgery? *

Are you allergic to local anesthetics? *

• Yes
• No

Are you allergic to latex? *

• Yes
• No

Do you take any blood thinners, aspirin, or anti-inflammatories? *

• Yes
• No

Do you take any medications that interfere with your immune system, including medications for arthritis, chemotherapy, or steroids? *

• Yes
• No

Have you ever been diagnosed with HIV/AIDS, or Hepatitis B or C or other infectious hepatitis? *

• Yes
• No

Do you have an active or untreated sexually transmitted disease? *

• Yes
• No

Conditions:

I have read the vasectomy information on this website (www.willowclinic.ca) including all the FAQ’s, ‘Risks of Vasectomy’, ‘Instructions Before Vasectomy’, and ‘Instructions After Vasectomy’. *

• Yes
• No

I understand that this is a booking form only and that once my form has been reviewed, I will be contacted with a virtual consultation time and a procedure time. The risks and limitations of vasectomy will be discussed at the consultation appointment. *

• Yes
• No

I understand that time is being set aside by the doctors to accommodate me. I understand that unexpected findings in my history or examination may result in the cancellation of the procedure appointment, for safety reasons. *

• Yes
• No

If I miss or cancel the procedure appointment with less than 2 full business days’ notice, the cancellation fee is $200.00. *

• Yes
• No

If I show up for the appointment and I am inadequately prepared, or if the information on this application form is incorrect or incomplete such that the vasectomy cannot be performed, I understand that I will be charged a procedure cancellation fee of $100.00. *

• Yes
• No

You will be asked to keep a credit card # on file with us. There will be no charges made unless we need to charge either of the fees above. *

• Yes
• No

By clicking the submit button, I acknowledge that I have read and understand these conditions. *

• Yes
• No

Phone

Submit

Thank you.