Same day Vasectomy Intake Form Fill out this form to have a SAME DAY VASECTOMY! Same Day Consult. No Wait. Drive In & Drive Out! Vasectomy intake formFirst Name Last Name Email Phone/Mobile Age Do you have children? Yes NoHave you got a bleeding disorder? Yes NoDo you suffer from any genetic conditions? Yes NoDo you take any blood thinning medications? e.g. Aspirin, Fish Oil, Warfarin or any other anticoagulants? Yes NoDo you suffer from Diabetes? Yes NoDo you suffer from any autoimmune conditions? Yes NoDo you have any allergies? Yes NoPlease list your allergies Have you had scrotal, inguinal hernia or testicular surgery? Yes NoWhat is your height (cm) What is your weight (Kg) Which location would you like your Vasectomy? Dandenong Hoppers Crossing South Melbourne CoolarooWhat time/day would you like us to contact you (Mon-Fri)? Monday (9am-1pm) Monday (2pm-6pm) Tuesday (9am-1pm) Tuesday (2pm-6pm) Wednesday (9am-1pm) Wednesday (2pm-6pm) Thursday (9am-1pm) Thursday (2pm-6am) Friday (9am-1pm) Friday (2pm-6pm)Deposit (If you are cleared medically) We will contact you at your desired date and time 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. Submit Form
