Pre-Vasectomy Summary

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Please review this information, initial after each point, and sign at the bottom:

1. I have read the vasectomy information sheet which I have initialed, I understand it, and have no additional questions at this time. ____.

2. This operation CAN fail to achieve sterility _____

3. This operation may work initially and then fail later within the first year ____

4. I know that the operation is a success when semen analysis confirms zero sperm (OR rare mon-motile sperm) after 20 ejaculate_____

5.I bring in semen sample for analysis after 20 ejaculates (roughly 10 weeks after vasectomy)_____

6.It will be safe to have intercourse without using some form of birth control once ZERO sperm (or rare non-motile sperm) have been confirmed. ____

Name: _____________________________________

Signature: ___________________________________

Date: _______________

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