Vasectomy Consent Form printable pdf download

Vasectomy Consent Form

Patient Consent

Name:

Phone:

Address:

ID No.:

Chart No.:

I, the undersigned…

Verify that I am over

years of age.

Understand the pain, discomfort, risks, benefits and recovery time associated with this procedure.

Understand that this procedure may not be reversible.

Understand that after this procedure takes effect I will not be able to father children.

Have been informed of other birth control options, including

Have rejected the aforementioned temporary options and have chosen a vasectomy.

Understand that I have

days until the surgery and that I can revoke my consent at any time

without penalty or loss of benefits

Understand that the procedure may take up to 6 weeks and 15 ejaculations to take effect and that I am

advised to use contraceptives until a test result verifies that I am no longer producing sperm.

Understand that the procedure may not work and that I may retain fertility or become fertile again in

the future.

Verify that the doctor has explained the aforementioned information to me in detail and has answered all

questions I had.

Patient Signature

Date

Physician Statement

Doctor Name:

Hospital:

I, the consulting physician…

Hereby state that to the best of my knowledge, the patient is over

years of age, mentally

sound and physically capable of undergoing the surgery.

Explained the resulting benefits, risks, pain and discomfort of this procedure to the patient.

Believe that the patient understands that the procedure may result in permanent, irreversible sterility but

may also result in sustained or returned fertility.

Believe that the patient understands the waiting period and test required for full sterility assurance

Ensured that the patient voluntarily consented to this operation and understands that consent can be

revoked at any time.

Swear that I have explained the aforementioned information to the patient in detail and have answered all

questions asked.

Physician Signature

Date

Witness Statement

, hereby swear and confirm that I witnessed the physician inform the

patient of the aforementioned information and that the witness did sign the document in his or her own hand.

Witness Signature

Date

Vasectomy Consent Form

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