Request a Vasectomy - Riversdale Surgery

Please click the vasectomy overview link below before completing the form to understand the risks and benefits of the procedure

Please complete the form below to request a vasectonmy.

Surname

Forename(s)

Date Of Birth

Address

Postcode

Mobile Number

Email Address

Medical History

Reason sterilisation required

Number of children

Age of youngest child

Height

Weight

Body Mass Index (MBI - if known)

Smoking Status

Current Contraception Used

Other contraception's considered and details of any intolerance

Please details any previous testicular history, other operations and relevant history

Current Medications

Known allergies

Any Other Comments

Is an interpreter required?

Yes

If yes, what language?

I confirm I have read the vasectomy overview information

Yes