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Vasectomy Clinic in Fredericton NB

No Scalpel Vasectomy
Circumcision
Penile Frenulectomy
Contact
About
FR

No Scalpel Vasectomy
Circumcision
Penile Frenulectomy
Contact
About
FR

Vasectomy Registration

Please complete the registration form below for no-scalpel vasectomy.

We will call you back to confirm your appointment and answer your questions.

Thanks for booking with us.

Patient Information
Name**
First Last
Address**
Street Address City Province Postal Code
Health Card Number**
Date of birth*
MM slash DD slash YYYY
Preferred Phone Number**
Alternative Phone Number (such as work phone)
Email**
Emergency Contact Name**
First Last
Emergency Contact Phone**
How did you hear about us?**
- Online / Google
- GP / Doctor's Referral
- Friend / Family Member
- Radio
Referring Doctor
Referring Doctor's Name
First Last
Referring Doctor's Phone
Work
Occupation**
Is your job physical?**
- Yes
- No
Family Information
What is your current relationship status?**
- Single
- Common Law
- Married
- Divorced
- Separated
Length of relationship:**
Type "N/A" if none
Partner’s Age:**
Type "N/A" if none
Do you have children together?**
- Yes
- No
Age(s):**
Type "N/A" if none
Do you have children from a previous relationship?**
- Yes
- No
Age(s):**
Type "N/A" if none
Does your partner have children from a previous relationship?**
- Yes
- No
Age(s):**
Type "N/A" if none
Is your partner currently pregnant?**
- Yes (If yes, complete delivery date below)
- No
Delivery date if partner is pregnant:
Contraception
What method(s) of contraception do you use?**
- Birth control pill
- Condom
- Diaphragm
- Cervical cap
- IUD
- Depoprovera
- Tubal Ligaton
- Rhythm
- Withdrawal
- Other (please specify below)
If "other" please specify method:
Medical History
Please check any of the following that apply to you: (Please tick all that applies)**
- Ache, pressure or pain in the testicle or groin
- Bleeding problems (including family history of it)
- Depression
- Epilepsy
- Hepatitis A, B, C
- Prostatitis
- Diabetes
- AIDS
- Genital warts
- Herpes
- Scrotal or testicular injury or trauma
- Undescended testis
- History of fainting due to medical procedure or injection
- Are you bothered by a tight band on the underside of your penis causing pain or bleeding during sex?
- Have you ever considered having a circumcision for any medical or personal reasons?
- Other (please specify)
- NONE OF THE ABOVE
If "other" please specify:
Surgical History
Please check if you have had any of the following:**
- Inguinal or sports hernia in the groin area
- Previous vasectomy
- Vasectomy reversal
- Scrotal or testicular surgery (including lowering of undescended testis)
- NONE OF THE ABOVE
Medications
Please list any medications you are taking including name and dosage: (including Aspirin, Advil, other anti-inflammatories)**
Type "N/A" if none
Allergies
Please list your allergies**
Type "N/A" if none
Height & Weight
Waist Line**
Height**
Weight**
Premium Service
Will you be choosing Premium Service? (Strongly Recommended)**
Includes: 1) NO-NEEDLE ANAESTHESIA to improve your comfort. 2) ALL AFTERCARE SUPPLIES to save you time. 3) FOLLOW-UPS BY PHONE so you don't have to travel back to the clinic. (See Vasectomy Fees page for more detail on this optional uninsured service)
- Yes, I would like Premium Service
- No, I do not want Premium Service
Vasectomy Agreement
You must consent to the following:
*
- I have read all of the information on the website regarding no-scalpel vasectomy*
*
- I understand that I require a physician referral to finalize my procedure booking (a walk-in doctor is perfectly fine as well if you don't have one - we can help).*
*
- I understand all the potential complications of the surgery including scrotal hematoma, infection, epididymitis, sperm granuloma, post vasectomy pain syndrome and late failure.*
*
- I know I should not drink alcohol for 48 hours before and for 48 hours after the procedure.*
*
- I know I must not take aspirin (ASA), anticoagulants (warfarin), or anti-inflammatories (NSAIDS) such as ibuprofen, Advil, Motrin, Aleve, etc, 7 days before the procedure and for 2 days after.*
*
- I have discussed having a vasectomy with my partner and they are supportive of my decision (Please call our office to discuss if this is not the case).*
*
- I understand that if I book my vasectomy and do not show up OR if I cancel my vasectomy with less than 2 business day’s notice OR if I do something I was clearly instructed not to do (ie. Take ASA, NSAIDS or anticoagulants within the previous week) thereby requiring my surgery to be cancelled, I am required to pay a $150 cancellation fee.*
*
- I have read the section on Fees and understand that NB Health only covers the very basic costs of a vasectomy. I understand that the popular Premium package is optional but highly recommended for improved comfort and convenience as it is a one-time fee for a once-in-a-lifetime procedure.*
Name
This field is for validation purposes and should be left unchanged.

Fredericton Circumcision Centre

Call now: 506-443-7623 | CONTACT

1015 Regent Street, Suite 304
Fredericton, N.B., E3B 6H5

Fax: 506-206-5701

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