NOTE: Please only complete this questionnaire if you have been instructed to do so by a member of our team.
Email Address
Your Name
What do you do for a job?
Does your job involve heavy lifting?
Do you want us to give you a sick note?
Do you have any medical conditions? If so, please list them:
Are you on any regular medication? If so, please list them below
Do you have any allergies - Local anaesthetic, Elastoplast, antibiotics?
Have you had any surgery in the groin area?
Do you have any issues with erections or ejaculations?
How long have you been with your partner? What do you currently use for contraception? How many children do you have? Does your partner or children have any medical problems that might influence your decision about vasectomy?
Have you looked at the slide presentation? If you can't access it please look on our website www.longlanesurgery.co.uk/vasectomies Are you clear that vasectomy is not 100% effective and is, for most men, not reversible? Do you have any specific worries or issues that you want us to address when we counsel you? Are you happy to be booked for surgery?
