I,                     [Name of Patient]                      ,           [Age of Patient].         of                         [Home City and Province of Patient].                             hereby authorize Dr. Khosro Refaie Shirpak and any assistant he may designate to perform No-Scalpel Vasectomy on myself. 

 

I fully understand that this procedure is performed through small scrotal punctures and that a small segment of each vas deferens is removed.

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I fully understand that this operation will cause sterility in the person operated upon. It means that the person will no longer be able to produce children or cause pregnancy in a female partner. This is usually, but not always, permanent.

 

I fully understand that that there is a possibility of failure and that I may not become or remain sterile.

 

I further realize and understand that it will be necessary for me to have my semen checked and examined at regular intervals for some time in order to be certain there is no recanalization and that I should continue to use another method of contraception until my sperm counts are negative.

 

I have been sufficiently discussed that, as any other operation there are known and unknown risks and complications associated with no-scalpel vasectomy including but not limited to: bleeding, bruising, infection or pain that may require further medical treatment or surgery.

 

I understand that if I change my mind in the future the chance of recanalization (reversal) is small, and that the reversal procedure is expensive and not covered by OHIP.

 

The reasons for the procedure, as well as the anticipated effects, nature and risks associated with it have been explained to me by Dr. Khosro Refaie Shirpak.

 

I request this operation voluntarily, of my own free choice. I have carefully read or had read to me the above, and I understand and accept the terms and conditions.

 

I also consent to such additional or alternative diagnostic or treatment procedures as are immediately necessary in the option of the Health Professional performing the procedure.

 

I certify that I am fully aware of and understand the contents of this Consent.

 

 

 

Patient’s Signature: ___________________________________________    Date:  ________________________________

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