Testing form -

Demographics

First Name *

Preferred name (how you prefer to be addressed) *

Last Name *

Mailing Address

Postal Code

Date of Birth *

Family Physician *

Alberta Health Care Number *

Occupation

Phone Number *

Email Address *

Level of exertion at work:

Before submitting the form, please review and agree to the following by checking the box:

You have read the information provided on our website regarding no-needle, no-scalpel vasectomy.

If you have a history of fainting, it's advised to bring a driver with you for the procedure.

Refrain from alcohol consumption 24 hours before and after the procedure.

Avoid taking aspirin or anti-inflammatory drugs (NSAIDs) such as Ibuprofen, Advil, Motrin, Aleve, etc., for 7 days before and after the operation unless advised otherwise.

If you are taking Warfarin, Apixaban (Eliquis), Rivaroxaban (Xarelto), Dabigatran (Pradaxa) or Edoxaban (Lixiana), please ensure you have listed it in the appropriate box above and Dr. Randeva will call you directly to discuss what to do. Do not just stop it.

Have a discussion with your partner about the decision to undergo a vasectomy, and ensure they are supportive of your choice. Feel free to contact our office to discuss further if needed.

You will have ample opportunity to ask any questions or discuss concerns with Dr. Randeva prior to your procedure.

Be aware that failure to follow Before Vasectomy Instructions or cancellation with short notice may incur a $200 cancellation fee.

Patient Signature *

Date *

Specialty Clinics

Toll Free 1-833-738-7325

info@peakmedicalgroup.ca

Have you had any of the following operations? (check Yes or No):

Have you ever had any of the following problems? (check Yes or No):

Before submitting the form, please review and agree to the following by checking the box: