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

  • Referring Doctor

  • Family Information

  • Type "N/A" if none
  • Type "N/A" if none
  • Type "N/A" if none
  • Type "N/A" if none
  • Type "N/A" if none
  • Contraception

  • Medical History

  • Surgical History

  • Medications

  • Type "N/A" if none
  • Allergies

  • Type "N/A" if none
  • Premium Service

  • 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)
  • Vasectomy Agreement

    You must consent to the following:
  • This field is for validation purposes and should be left unchanged.