Please note that if you answered "Yes" to the above question, we strongly recommend you have someone drive you to and from your appointment.

• An explanation of what a vasectomy is
• Alternatives to vasectomy that I could consi

  der
• Details on how the procedure is performed
• Expected recovery time
• Precautions during recovery, including recom

  mended rest and restrictions on exercise, se

  x, and heavy lifting
• Risks and potential complications of vasecto

  my and their likelihood
• Requirement of a sperm test three months aft

  er the vasectomy to confirm effectiveness

1. I understand the vasectomy procedure and its

   associated risks.
2. I acknowledge other available procedures and

   treatment options, along with their associa

   ted risks.
3. I understand that vasectomy is not my only o

   ption for contraception. Alternatives includ

   e condoms, abstinence, or female contracepti

   on methods (e.g., the pill, long-acting cont

   raceptives like Implanon, Mirena, or a three

   -month depot injection) to avoid unintended

   pregnancies.
4. I give permission to doctors and nurses to t

   reat me in the event of a life-threatening e

   mergency during the procedure.
5. I confirm that I had the opportunity to ask

   questions and raise concerns about the vasec

   tomy, its risks, and other treatment options

   , both before and on the day of the procedur

   e. My questions and concerns have been addre

   ssed to my satisfaction. I understand that I

   have the option to defer my procedure and r

   eflect further based on the in-person consul

   tation.
6. I understand that Dr. Cashion will, unless o

   therwise requested, use two or more small ti

   tanium clips to secure tissue around one end

   of the vas deferens during the operation. I

   am aware that these clips will remain in my

   scrotum permanently, but I can opt for abso

   rbable sutures instead by notifying Dr. Cash

   ion before my surgery. (Dr. Valentine and Dr

   . Kalau use only absorbable sutures.)
7. I understand my right to change my mind at a

   ny time, including after signing this form.
8. I acknowledge the requirement for a semen te

   st approximately three months post-procedure

   to confirm that the vasectomy was successfu

   l and that I am sterile. I understand that u

   ntil I am advised otherwise, I should consid

   er myself fertile and use contraception.
   Additional fees usually apply for this se

   men test through an external pathology la

   b, which are separate (and not included)

   from the fees paid to Vasectomy Australia

   .
9. I understand there is a chance the procedure

   may not be effective, and I could remain fe

   rtile after the vasectomy.
10. I have been advised to avoid strenuous exerc

    ise, heavy lifting, and sexual activity for

    at least one week following my vasectomy, an

    d to abstain from bike riding and contact sp

    orts for at least three weeks.
    
    
    I understand that vasectomy is a permanent f

    orm of sterilisation, and after this procedu

    re, I will not be able to father children.
11. If the procedure cannot be completed or fail

    s, I understand that I may need to be referr

    ed to a surgeon and am responsible for any f

    ees incurred.
12. I understand that post-operative complicatio

    ns may require referral to a specialist, suc

    h as a urologist or general surgeon, and I a

    m responsible for any fees.
13. I agree to receive my sperm test results fro

    m Vasectomy Australia via phone call, SMS or

    email.
14. I confirm that Vasectomy Australia has advis

    ed me to have someone drive me home after my

    vasectomy. If I must drive myself, I agree

    to wait at least 20 minutes post-procedure.

    I will not drive if I feel lightheaded or di

    zzy until these symptoms fully resolve.
15. I assign my right to Medicare benefits to Dr

    . Geoffrey Cashion, Dr. Matthew Valentine, D

    r. Marcel Kalau, or their delegate doctor fo

    r the following services to allow them to be

    bulk billed:
    
    
    Item 23 (or Item 5020

    if on a Saturday after

    1 pm):
    Level B GP attendance, assigned benefit of

    $42.85 ($55.80 for Item 5020) for the in-per

    son consultation on the date of my vasectomy

    .
    
    
    Item 9

    1891:
    Level B phone consultation, providing a $42

    .85 benefit for discussing post-vasectomy se

    men test results, post-operative recovery, a

    nd preventative health, up to 12 months post

    -procedure.
    
    
    Item 9

    2734:
    Level B phone consultation, providing a $42

    .85 benefit for discussions on reproductive

    or sexual health at any time before or after

    my vasectomy.
16. I consent to my doctor or their delegate obt

    aining my Medicare Card details through Medi

    care Australia's PRODA online system for bul

    k billing my pre-vasectomy and any other con

    sultations, as well as processing payment fo

    r my vasectomy (Item 37623) to allow a rebat

    e to be credited to my account or by cheque.

Based on the above information, I, George Pseftelis, consent to having a vasectomy under local anaesthetic

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