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Vasectomy Clinic in Fredericton NB

No Scalpel Vasectomy
Circumcision
Penile Frenulectomy
Contact
About
FR

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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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