PATIENT DETAILS

    ABOUT YOU

    Name

    Address

    Date of Birth

    Height

    Weight

    Name and address of your GP

    Occupation

    Email

    Home Telephone number

    Mobile Telephone number

    Preferred contact method

    ABOUT YOUR VASECTOMY

    How long ago was your vasectomy

    Have you already had an attempt at vasectomy reversal

    ABOUT YOUR HEALTH

    Do you have any medical problems

    Do you have any chest, breathing or heart problems?

    Have you had any form of surgery?

    Are you on any medications and what are they?

    Do you have any allergies

    Have you or a close relation had any problems with a general anaesthetic?

    ABOUT YOUR PARTNER

    How old is your partner?

    Has she had children previously?

    Does your partner have any known potential fertility problems?