Vasectomy Consent Form Vasectomy Consent Form Patient Details Full Name: * Date of Birth: * Please use date format DD/MM/YYYY Phone Number: Email Address: * Your Consent I consent to undergo a vasectomy * I understand the intention of the operation is to make me unable to have children * I understand the operation is permanent and an attempted reversal has a limited chance of success and is not funded by the NHS * I understand that I should provide a sperm specimen 12 weeks after the operation to confirm my sterility. Until this has been confirmed my partner and I must continue to use contraception * I understand that a vasectomy can fail even after a negative sperm count. * I understand that a vasectomy carries a risk of swelling (1 in 10) and infection (1 in 100) * I understand that following a vasectomy I have a low risk of developing a persistent scrotal discomfort which can detract from my quality of life and may be difficult to successfully treat * Signed * Date Submit