Please read this form very carefully. If there is anything that you don't understand about the explanation, or if you want more information, you should ask the doctor. Please check that all the information on the form is correct. If it is, and you understand the explanation, then sign the form.

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I am the patient, and I agree:-

To have this vasectomy as has been explained to me by the doctor.
To have the type of anaesthetic that I have been told about.

I have been given relevant leaflets explaining the procedure and its possible complications. I understand:

That the aim of the operation (removal of small segment of Vas from both sides) is to stop me having any children and it might not be possible to reverse the effects of the operation.
That vasectomy can sometimes fail and that there is a very small chance that I may become fertile again after some time.
That any procedure in addition to the investigation or treatment described on this form will only be carried out if it is necessary and in my best interests and can be justified for medical reasons.
Common post-op effects include small amount of scrotal bruising
Occasional post-op complications are bleeding requiring further surgery or extensive bruising
Rare complications are: inflammation or infection of testes or Epididymi, requiring treatment, failure of sterilization (resulting in pregnancy 1in 2000) and Chronic Testicular pain or Granuloma

For vasectomy I understand:

That I may remain fertile or become fertile again after some time.
That I will have to use other contraceptive methods until at least 1 sperm count test shows that I am not producing sperms, if I do not want to father any children.