Download 689 kB 5th Feb 2015 VASECTOMY CONSENT FORM

Gentle ProceduresClinic
East GTA
Dr. An-Huy Nguyen, MD, C.C.F.P.
Mailing Address:
Gentle Procedures Clinic, East GTA
Suite 101
4125 Lawrence Avenue East
Scarborough, ON M1E 2S2
Circumcision/Vasectomy
416.281.8088
416-281-8081
[email protected]
www.gentleprocedurescliniceastgta.ca
VASEC TOMY CONSENT FORM
I,
please print
, the undersigned, request that a vasectomy be performed on my person.
I make this request of my own free will, without having been forced or given any special inducement.
I understand the following:
There are temporary contraceptive methods available to my partner and me.
The procedure to be performed on me is a surgical procedure, the details of which have been explained to me.
This surgical procedure involves risks, in addition to benefits, all of which has been explained to my
satisfaction.
If the procedure is successful, I will be unable to have any more children; however, the procedure does not
protect me or my partner from infection with sexually transmitted diseases, including HIV/AIDS.
The effect of the procedure should be considered permanent. (i.e. it may NOT be possible to reverse your
vasectomy with a subsequent surgery.)
I can decide against the procedure at any time before the operation is performed (without losing the right to
medical, health, or other services or benefits).
I agree to have at least 2 semen analysis checks done after my vasectomy to ensure it was successful.
Without these I will not know if my procedure was successful. I understand that there is no fool proof
contraception method of any kind that exists today. I understand that even after 2 sperm tests showing
no moving sperm present, I can still cause a pregnancy months or years later, however this is highly unlikely.
( 1 in many 1000’s )
I agree to come in to the office to have my semen results discussion with Dr. Nguyen. I understand that the
staff cannot discuss this with me over the phone.
I agree that any legal proceeding or cause of action arising out of the vasectomy will be commenced in and
only in the Province of Ontario and shall be governed only in accordance with the laws of the Province of Ontario.
I agree that I have not taken any anti inflammatory medications within the last 7 days i.e. Aspirin, Advil,
Ibuprofen, etc.
I understand that a syndrome exists called “Sudden Infant Death Syndrome” where babies a few months
of age can spontaneously die (this is brought to your attention in case you have a new infant)
PATIENT SIGNAT URE
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Please see reverse for additional information.
Gentle ProceduresClinic
East GTA
Circumcision/Vasectomy
Vasectomy Consent Form | Page 2 of 2
I understand that RISKS AND POSSIBLE COMPLICATIONS include:
A bruised sensation to the scrotum for a few days to a week after the procedure.
Some mild bleeding into the scrotum (1/100) which may form a small tender swelling for a few days.
Scrotal hematoma (1/2000) – a major bleed into the scrotum causing a grapefruit size tender scrotum
disabling you for 2 months.(You should page Dr. Pollock immediately if you notice any significant swelling
in your scrotum after your procedure.)
Infection which may require antibiotics (1/100 ). More serious infection is possible i.e abscess formation that
may require intravenous antibiotics.
Epididymitis – tender swelling of the epididymis which is the part of the tube that joins to the testicles (1/50).
It almost invariably resolves with anti-inflammatories, ice and rest.
Sperm granuloma – a painful lump that may develop at the site where the tube was blocked made of leaked
sperm (1/500 ), same treatment as above usually effective.
Post vasectomy pain syndrome (1/1000) – a very rare complication of pain in the testicles that can persist
for months or years and may be quite debilitating. Some men may never completely recover from this
problem or it may resolve on its own or another surgical procedure may be required.
Other complications have been reported (1/10,000)
Some studies have reported a small increase in prostate cancer after vasectomy. Many other studies have
shown no increased risk. Most experts agree that vasectomy does not cause cancer.
Late failure – a rare outcome in about 1/3000 men who even after a successful vasectomy with 2 sperm
checks showing no sperm seen, still manage to impregnate their partner.
PLE ASE INITIAL HERE
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