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

  • 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. 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 $199 optional uninsured service.
  • Vasectomy Agreement

    You must consent to the following: