Vasectomy

Vasectomy History Form

Please fill out the below form. The only questions you are required to answer have a red star next to them. These are typically done on Mondays and Thursdays between 9 and 3. Once we receive your form we will contact you via text message or a phone call to schedule your appointment.
Patient name*

First NameLast Name
What is your middle initial?
Date of birth*

MonthDayYear
Date
Email*
example@example.com
What is your cell phone number*
Please enter a valid phone number.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

MaleFemale
Marital Status:

SingleMarriedWidowed
Social Security Number
Race*

WhiteBlackAsianAmerican Indian or Alaskan NativeNative Hawaiin or Pacific islanderOther
Are you Hispanic or Latino

YesNo
Language*
Referring Doctor (if any)?
Primary Care Doctor?
Preferred pharmacy?
Location of preferred pharmacy?
Emergency contact:*
Emergency Contact Phone Number:
Please enter a valid phone number.
Relationship:*
How did you hear about us?

OnlineFriendProviderOther
Who referred you?
Person responsible for Bill:*
Address if Different from Above?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Primary Insurance:
Group Number:
ID Number:
Subscriber Name:

First NameLast Name
Subscriber date of birth:

MonthDayYear
Date
Secondary Insurance (if you have it):
Group Number:
ID Number:
Subscriber Name:

First NameLast Name
Subscriber date of birth:

MonthDayYear
How do you plan to pay for the procedure?*

$300 cashInsuranceI can't afford the procedure and would like to discuss a lower cost optionUnsure
How old are you?*
Please list any medical problems that you have (write "none" if none).*
Please list any medications that you take (write "none" if none).*
Please list any allergies to medications that you have (write none if you don't have any).*
How many children do you have?*
Are you married or in a stable relationship?*

YesNo
Do you understand that vasectomy is to cut the tubes carrying your sperm so that you cannot biologically father any more children?*

YesNo
Do you understand that it will take 12 weeks for the sperm present in your tubes to “wash out” and that you should use a form of contraception until after you have had your semen tested and found to be clear of any sperm?*

YesNo
Do you understand that vasectomy REVERSAL is complicated surgery that may not work and that you should not proceed with vasectomy if you think that you will change your mind about biologically fathering children in the future?*

YesNo
Do you wish to proceed with elective sterilization by vasectomy?*

YesNo
Description: A vasectomy is a surgical procedure that occludes the vas deferens (the tube that carries sperm from the testicle). THISPROCEDURE SHOULD BE CONSIDERED PERMANENT. It is intended for men who never want to have more children. ***Advantages: Vasectomy is usually performed in the office using local anesthesia. It is greater than 99% effective and is as effective, or more effective, than all other forms of birth control except abstinence (when actively practiced). There is no effect on sexual function. ***Disadvantages: Vasectomy is a minor surgical procedure. It is not immediately effective and should be confirmed with a semen analysis. It does not protect against sexually transmitted diseases. Vasectomy cannot be reversed in a lot of cases and so should be considered permanent. ***Risks: Bleeding- This is uncommon. It can result in significant bruising of the testicle and rarely may require intervention. Infection- rare cases occur and could result in the need for antibiotics or surgery. Sperm granuloma- A small lump that occurs at the site of the vasectomy. These are considered normal, but can rarely cause symptoms and may require further surgery. Failure- This happens less than 1% of the time. This can occur early when the vasectomy doesn’t remove all the sperm from the tube. You must use an alternative form of birth control until a semen analysis shows there is no sperm in your semen. This also can occur at a later time in the rare case that the Vas grows back together. Vasal pain- This is very uncommon(less than 1%) and typically requires intermittent use of ibuprofen. Very rarely more serious chronic pain has been described. ***Alternatives: There are many other forms of birth control that can be used instead of vasectomy. Each method has its own risks and benefits. Some common alternative forms of birth control include: hormonal birth control, IUDs, condoms, diaphragm, tubal ligation, and abstinence. ***I have read the information above and have had all questions answered to my satisfaction. I understand that there is no absolute guarantee that this method of birth control will be successful. I understand that an alternative form of birth control should be used until semen analysis shows that there are no sperm. *

Clear
I acknowledge that this information provided to Kitsap General Surgery is accurate and current.*

Clear
For post-vasectomy semen analysis, Kitsap General Surgery will order this through an outside organization (St Michael's in Silverdale or one that is local to where you live). This organization will charge for the semen analysis. I understand that the post-vasectomy semen analysis isn't covered in the fee charged by Kitsap General Surgery.*

Clear
Financial Policy, Assignment Information, and Release of Information
I authorize release of any information acquired in the course of treatment necessary to complete and file medical claims to my insurance company or Medicare on my behalf. I herby acknowledge financial responsibility for cost of services rendered for me or for the person whose account I am acting as guarantor. I authorize (assign) any insurance or Medicare benefits to be paid directly to Kitsap General Surgery, PLLC or its assignees. I am responsible for any non-covered services, supplies, co-payments or deductibles. I am responsible for knowing how my plan works when I request medical services at this office. This acceptance and assignment will be in force all future services by practitioners from this office.
Signature of patient or patient's guardian/representative?*

Clear
Name of person who signed above.*

First NameLast Name
Date

MonthDayYear
Acknowledgement of Notice of Privacy Practices
I understand that as part of my health care, Kitsap General Surgery originates and maintains paper and/or electronic records describing my health history, symptoms, examinations, and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:

   A basis for planning my care and treatment,

               A means of communication among the many health professionals who contribute to my care,

               A source of information for applying my diagnosis and surgical information to my bill,

A means by which a third-party payer can verify that services billed were actually provided, and

             A tool for routine healthcare operations such as assessing quality.

Kitsap General Surgery has a responsibility to protect the privacy of your health care information and to provide a Notice of Privacy Practices that describes how your health care information may be used and disclosed, how you can access your health information, and whom to contact if you have any questions, concerns, or complaints. We may change the Notice of Privacy Practices at any time. You may obtain a current copy of the Notice of Privacy Practices or ask questions at anytime.

I have had an opportunity to receive and review the Notice of Privacy Practices of Kitsap General Surgery.
Signature of patient or patient's guardian/representative?*

Clear
Name of person who signed above.

First NameLast Name
Date

MonthDayYear
Release of Medical Information

Please list the individuals you allow us tocommunicate with regarding your care.
Name of Individual

First NameLast Name
Relation
Phone Number
Please enter a valid phone number.
Name of Other Individual

First NameLast Name
Relation
Phone Number
Please enter a valid phone number.
Should be Empty:

Vasectomy History Form

Financial Policy, Assignment Information, and Release of Information

Acknowledgement of Notice of Privacy Practices

Release of Medical Information