So Simple Vasectomy - Online Registration Form

Submit this registration ONLY if you have obtained a referral from your doctor.

Dr. DeBolster advises that you make a specific appointment with your family doctor to discuss these issues. Your referral should specifically state that your Doctor is in agreement with your decision for having a vasectomy before faxing the referral to our office.

Before you register online, you must:

  1. Have a recent referral from your doctor.
  2. Read the Vasectomy Information found here and ensure all your questions have been answered.
  3. Be sure that you do not want to bank sperm prior to vasectomy. If you are not sure, phone us for a consultation.

Once you submit this registration:

  1. Our office will phone you to book your vasectomy, or to discuss the need for an office consultation.

Deal-breakers
Dr. DeBolster reserves the right to postpone or cancel your vasectomy for any of the following reasons:

  1. Aspirin (ASA) or blood thinners (Coumadin) taken within 7 days of the procedure.
  2. Technical issues. The rare patient will have a scarring or some other condition at or near the vas, e.g. hernia repair.

If you have any questions phone 905-338-8222. If you would like to proceed with registration, please fill out this form completely and submit.

We look forward to seeing you in a few weeks!

Required Information

Personal Information

Last Name: (required)
First Name: (required)
Date of Birth: MM DD YY
Ontario Health Card Number (OHIP):
Version Code:
Name as printed on your OHIP Card:


Contact Information

Address:
City:
Province:
Country:
Postal Code:
Home Phone:
Work Phone:
Cell Phone:
Preferred Phone:Cell Home Work
Email Address: (required)


Occupation

Job Description:
Level of exertion at work:Sedentary Light Physical Heavy Physical


Referring Physician (DOCTOR'S REFERRAL IS MANDATORY.)

Referring Physician's Name:
Phone Number:


Family

Are you currently in a relationship?:No Yes
Type of Relationship:Married Common Law
Length of Relationship:
Do you have any children together?:No Yes
How many (if yes):
Do you have any children from previous relationships?:No Yes
How many (if yes):


Current method/methods of birth control:

None
Avoidance
Withdrawal
Rhythm
Condoms
Diaphragm
IUD
Birth Control Pill
Depro Provera Shot
Other


Medical History

Height (Ft, In):
Weight (lbs):
Waist Size:
Do you engage in strenuous physical activity or sports?No Yes
Do any of the following apply to you? (required). If so, please check the appropriate box(es)
Yes No (required)

Bleeding Disorder No Yes
Hepatitis No Yes
HIV No Yes
Hypertension No Yes


Have you had any operations in the past? (required). If so, please check the appropriate box(es).
Yes No (required)

Surgery to the penis or scrotum No Yes
Testicle Surgery No Yes
Previous Vasectomy No Yes
Vasectomy Reversal No Yes
Appendectomy No Yes
Coronary surgery No Yes
Hernia surgery No Yes
Other:

Are you taking any medication? (required). If so, please check the appropriate box(es).
Yes No (required)

Aspirin No Yes
Insulin No Yes
Antihypertensive No Yes
Lipid lowering drug No Yes
Other:

Do you have any allergies to any medications? (required). Please list.
Yes No (required)

Allergies No Yes
Medication List:


Appointment Schedule

Preferred Appointment Day:

How did you find us?



Vasectomy Preparedness

I confirm that I do not want to father any more children in my lifetime. No Yes

I decline pre-vasectomy sperm banking. No Yes

I have read all the information in the vasectomy handout and have had all my questions answered. No Yes

I know I must avoid aspirin, ASA, or any products containing this for 7 days pre-operatively. No Yes

I am aware of the restrictions on physical activity for the week following the vasectomy. No Yes