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

  • Date Format: MM slash DD slash YYYY
  • Type "N/A" if none
  • Referring Doctor - Optional

    Please complete only if applicable.
  • 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: NO-NEEDLE ANAESTHESIA for your comfort. INHALED NITROUS OXIDE (laughing gas) for relaxation. ALL AFTERCARE SUPPLIES to save you time. FOLLOW-UPS BY PHONE so you don't have to travel back to the clinic. Please see the Vasectomy Fees page for more detail on this $250 optional uninsured service.
  • Pre-Procedure Consult - By phone or at the clinic?

  • The phone consult option permits you to come to the clinic just for your procedure. Alternatively you can have a separate consultation appointment in the days before your procedure. The phone consult is an optional uninsured service that costs $75.
  • Vasectomy Agreement

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