WE REQUIRE SIGNED CONSENT BEFORE PROCEEDING WITH THE VASECTOMY. WE WILL PROVIDE YOU WITH A FORM TO SIGN AT THE OFFICE. PLEASE FEEL FREE TO DISCUSS IT WITH US FIRST BEFORE SIGNING IT.

I, (print)____________________________ the undersigned, hereby request and voluntarily consent to the operation of No-Scalpel Vasectomy to be performed by Dr. _________________. The doctor has provided me with information explaining that this operation is intended to result in permanent sterility, making me no longer capable of starting a pregnancy and fathering children. I also understand that the operation may not result in sterility and that no guarantee of sterility has been given to me.
I have been told that the operation has possible complications such as bleeding and pain.
Reuniting of the channels (spontaneous reversal) happens in approximately 0.1 % of men, usually within the first three months after the procedure.
If the vasectomy is successful, the chances of my fertility returning after negative sperm counts are extremely small.
I have been told that surgical reversal of vasectomy is possible but this does not necessarily result in a return of the ability to father children.
I have been advised that, because residual sperm is present above the site of the vasectomy after the operation, a semen test should be performed after 20 ejaculations in order to demonstrate that no sperm remain. I have been advised to wait at least 10 weeks before having the test to check for spontaneous reversal.
Each individual or couple may have different levels of comfort with the chances of a spontaneous reversal. For this reason, further tests may be done at the individual’s discretion.
I am aware that I will need to continue with another contraceptive method until tests are negative.
I have been informed of the usual post-operative care necessary to reduce complications arising after surgery.
I understand that if I choose to take a tranquilizer before the procedure it may make me too drowsy to drive safely, and I agree to arrange a ride home. If I decide to drive myself, I acknowledge that I have been advised by the doctor to not do so and I take full responsibility upon myself for my actions and their consequences.

I have read all the above and agree to these terms and conditions.

Signed____________________________ Date__________________

Witness___________________________

Rev. March ‘04