Same Day Vasectomy Form - Circumcision and Vasectomy

Vasectomy Intake

First Name

Last Name

Phone/Mobile

Age

Do you have children?

Yes

Have you got a bleeding disorder?

Yes

Do you suffer from any genetic conditions?

Yes

Do you take any blood thinning medications? e.g. Aspirin, Fish Oil, Warfarin or any other anticoagulants?

Yes

Do you suffer from Diabetes?

Yes

Do you suffer from any autoimmune conditions?

Yes

Do you have any allergies?

Yes

Please list your allergies

Have you had scrotal, inguinal hernia or testicular surgery?

Yes

What is your height (cm)

What is your weight (Kg)

Which location would you like your Vasectomy?

Dandenong

Hoppers Crossing

East Melbourne

Craigieburn

We will contact you to book your vasectomy.
Your vasectomy will be confirmed upon receiving a $200.00 deposit.
You can pay your deposit online. We will send you a link to pay your deposit after we have booked a date for your vasectomy.
Your deposit must be paid within 48 hours from your phone call.

Same Day Consult & Vasectomy Procedure