Please review this information, initial after each point, and sign at the bottom:
- I have read the vasectomy information sheet which I have initialed, I understand it, and have no additional questions at this time ____
- This operation CAN fail to achieve sterility _____
- This operation may work initially and then fail later within the first year ____
- I know that the operation is a success when semen analysis confirms zero sperm (OR rare mon-motile sperm) after 20 ejaculate_____
- I bring in semen sample for analysis after 20 ejaculates (roughly 10 weeks after vasectomy)_____
- 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: _______________
Informative Vasectomy links:
