Thank you for completing the online registration, your medical history will be reviewed by your treating doctor.
For all enquiries relating to a Vasectomy please complete all fields below.
- When submitting the form it will be encrypted and automatically transmitted to our office, we then add the form to your medical chart.
- By completing and signing the form electronically you are making an informed consent to the procedure being performed on the date of your appointment.
- If you do not consent to some or all of the sections do not submit the form and contact our office to discuss – 07 2103 2322.
- Please note most sections on this form require an entry, if you do not have the answer please enter n/a for not applicable. If you do not have your Medicare card please enter the number 0 in each cell.
- If you have a question or comment regarding the consent; complications; privacy or release of information sections, please enter the details of your enquiry or concerns in each note section.
- We kindly ask YOU complete the form and that you do not get a family member or friend to complete the registration form on your behalf.