vasectomy dotsVasectomy Consent Form

BILATERAL MALE VASECTOMY

I ..

Of ..

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

I understand :-

  • that it should make me incapable of fathering children
  • that it may not be possible to reverse the operation
  • that two consecutive semen tests must show no sperms are present
    before stopping other methods of birth control
  • that it will be done using a local anaesthetic
  • that no assurance can be given that the operation will be 100% safe or successful.

I have been warned of :-

  • the risk of failure ( early and late)
  • the risk of longterm pain
  • the risk of psychological problems.

Patient's signature: Date: .


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

Doctor's signature:. Date: .



AGREEMENT BY WIFE:

I too understand points 1 5 and 1 3 above, and agree to the performance of bilateral vasectomy on my husband.

Wife's signature: . Date: .



I have explained to the patient's wife the nature and purpose of the operation to which she has given her consent.

Doctor's signature: . Date: .