Vasectomy Consent - Acorn Surgery

Name

First Last

I have been counselled regarding alternative forms of long term reversible contraception, eg. coils / implants and have read and understood the information leaflet.(Required)

I also consent to such further alternative measures as may be found necessary or advisable during the course of the operation and to the administration of a local anaesthetic for any of these purposes.(Required)

I have been told that the object of the operation is to render me sterile and incapable of further parenthood and I understand that the effect of the operation may be irreversible.(Required)

Further I confirm that I acknowledge there is a rare but accepted failure rate associated with non-scalpel vasectomy reported to be in the order of 0.05 % (1 in 2000) and therefore a small risk of pregnancy in the future even after being given the ‘all clear’.(Required)

I understand that no guarantees can be given that the operation will be successful or that it will be free from side effects.(Required)

I acknowledge that there is a small risk of significant complications like severe infection and excessive bleeding / bruising (common to any surgical procedure – for non-scalpel vasectomy, less than 1%), a RISK of developing chronic testicular pain and extremely rarely: testicular atrophy.(Required)

I understand any complication may require further medical treatment, hospitalisation or further surgery.(Required)

I understand that I should not abandon other methods of contraception prior to receipt of notification that at least one sperm count at least 4 months after my vasectomy has proved negative, or special clearance has been given after 7 months.(Required)

I understand that I can change my mind at any time and decide not to proceed with the vasectomy.(Required)

Date of Procedure

Day

Month

Year

Past Medical History Optional

Allergies Optional

Current Medication Optional

Contraception Optional

Alternatives to vasectomy discussed

Yes

Any Questions? Optional

Patient Confirmation

I confirm that I have read (or had read to me) and understand the above form and I am satisfied with the conditions stated therein. Optional

Additional information Optional

Name of Doctor

First Optional Last Optional

Doctors Confirmation

I confirm that I have explained to the patient /and partner* the nature and effect of vasectomy as detailed above. Further, I confirm that the patient has read (or had read to him) the above form and I am satisfied that he understands what is proposed, has no further questions, and is happy to proceed with a vasectomy. Optional

Email Optional

This field is for validation purposes and should be left unchanged.