To be completed by the patient in his own handwriting:
1. I have read the vasectomy information sheet which
I have initialed, I understand it, and have no additional questions at
this time. ____ (fill in yes or no).
2. Can this operation fail? _____
3. Is it possible that this operation may work
initially and then fail later within the first year? ____
4. How will I know that the operation is a success?
________________
5. When should I bring in semen samples for
analysis? _____
6. When will it be safe to have intercourse without
using some form of birth control? ______________
Name: _____________________________________
Signature: ___________________________________
Date: _______________
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