VASECTOMY SERVICES


VASECTOMY CONSENT FORM

BILATERAL MALE VASECTOMY


I ............................................of...............................................................................

Consent to the operation of VASECTOMY, the nature, purpose and intended effect of which have been explained to me.

I understand		1. That it should make me incapable of fathering children:
			2. That it may not be possible to reverse the operation:
			3. That two consecutive semen tests must show no sperms are present  before stopping other methods  			    
			    of birth control:
			4. That it will be done using local anaesthetic:
			5. That no assurance can be given that the operation will be 100% successful:
			6. That I understand that I must take 3 days complete rest and 7 days further rest from strenuous 			   physical activity to prevent complications:

I have been warned of:    1. The risk of failure:
			  2. The risk of long-term pain:
                          3. The risk of local bleeding/infection post op.

Signed .............................................      Date ........................

I have explained to the patient the nature of the operation, to which he has given consent.

Signed .....................................(doctor)      Date ........................

AGREEMENT BY WIFE/PARTNER:

I too understand points No’s 1 to 5 and 1 to 3 above and agree to the performance of bilateral vasectomy on my husband/partner:

Signed .............................................      Date ........................

I have explained to the patients wife/partner the nature and purposes of the operation to which she has given consent.

Signed .............................................      Date ........................