Do you have a valid health card issued by the government of a Canadian province or territory?

What is your emergency contact's relationship with you?

What is your current relationship status?

Will you be storing sperm?

Will you be choosing the Premium Service? (strongly recommended*)

I have read the information on the website regarding no-scalpel vasectomy.

I understand the potential complications of the surgery including scrotal hematoma, infection, epididymitis, sperm granuloma, post vasectomy pain syndrome and late failure and have had all questions answered to my satisfaction.

I know I must not drink alcohol for 48 hours before and for 48 hours after the procedure.

I have read the section on "Fees" and understand that while my vasectomy is covered by the public health plan, the vast majority of patients purchase the Premium Package for improved comfort and convenience including the benefits of No-Needle Anesthesia.

I know I must not take aspirin (ASA), anticoagulants (warfarin), or anti-inflammatories (NSAIDS) such as ibuprofen, Advil, Motrin, Aleve, etc, 7 days before the procedure and for 2 days after.

Minor side effects: Immediately following vasectomy, minor side effects may include discomfort, swelling and/or bruising of the scrotal skin, all of which usually disappear without treatment. Some men will experience swelling and a low-grade ache in one or both testes anywhere from three days to six months after the procedure. This is due to an exaggerated form of the body's natural response to the obstruction caused by the vasectomy. It usually responds nicely to an anti-inflammatory drug, but for rare patients swelling and discomfort will occur more than once and/or will be severe enough to require prescription pain medications, stronger anti-inflammatory drugs, or more days off from work. A small number of men will develop a grape-sized hematoma (blood clot) after use of the spray applicator for anesthesia which typically is self-resolving over the course of 1-2 weeks.

Early complications: Hemorrhage and infection can occasionally occur after any surgery. Based on large-scale studies, the overall incidence of either hematoma (a blood clot in the scrotum) or infection is less than 2% of the vasectomies performed. Rarely patients may develop a subcutaneous hematoma after use of the spray applicator for anesthesia that may cause more noticeable and prolonged discomfort on that side. Very rarely, hospitalization and surgery may be required in the case of large hematoma or very severe infection (abscess). (Potential surgery may, for example, include drainage of a large clot or abscess through a scrotal incision in an operating room under general anesthesia). A Syncopal ("fainting") episode may rarely occur during or soon after the vasectomy procedure. It is thought that this may represent a sort of panic attack with the body's response being a drop in blood pressure and feeling cold/clammy. Although we do encourage patients to have a driver available after vasectomy, we routinely allow patients to drive themselves home after the procedure as long as no sedating medications were utilized since this is a routine office-based procedure analogous to visiting the dentist. Patients that drive themselves are mandated a 15-minute waiting period prior to getting in the driver's seat. Despite this waiting period, a syncopal episode while driving a motor vehicle after the procedure is still theoretically possible and may incur significant morbidity, unforeseen costs, or death.

Late complications: 1. A sperm granuloma is a pea sized sometimes-tender mass near the vasectomy site, above the testicle which results when the body reacts to and walls off sperm which may leak from the lower (testicular) end of the cut vas. A sperm granuloma may actually enhance the likelihood of reversal success. Some are tender enough to require removal in the office under local anesthesia

Late complications: 2. Post-vasectomy pain syndrome is defined as testicular pain (on one or both sides) for greater than 3 months after having a vasectomy, severe enough to interfere with daily activities and causing a patient to seek medical attention. Chronic pain may also be localized to the epididymis or the vasectomy site. Because chronic pain is so subjective, reported rates vary but compiled data would suggest that this is a significant problem for 1-2% of vasectomy patients, though it seems to be less common than this in our practice. In most cases, the pain is relieved with time and/or medication. Vasectomy reversal, removal of the epididymis, removal of vasectomy site, or a special procedure called neurolysis may rarely (less than 0.1%) be required to alleviate post vasectomy pain.

Late complications: 3.Vasectomy Recanalization/Failure . Recanalization is the re-establishment of sperm flow from the testis up to the rest of the reproductive tract by virtue of the cut ends of the vas growing back together after vasectomy. Early recanalizations occur during the healing process. They are detected at the time of follow-up semen checks when live (moving) sperm or significant numbers of non-motile (not moving) sperm are still seen in semen specimens within six months after the vasectomy. An unwanted pregnancy does not occur if the couple has used other forms of contraception as advised. Our rate of early recanalization is about 1 in 3000 patients. In the case of persistent sperm present in the semen, a repeat vasectomy procedure is required. Late recanalization refers to the return of live sperm to the semen at some time after the semen has been confirmed to be sperm-free by microscopic examination. Late failure resulting in pregnancy is possible but rare, odds being about 1 in 3000 over the lifetime of the patient, a rate of failure MUCH lower than with any other form of contraception. Our office does not require another semen check after the absence of sperm has been confirmed, but patients may return with a second sample any time after vasectomy to achieve an added index of confidence.

Late complications: 4. Anti-sperm antibodies do appear in the blood of about half of the patients who undergo vasectomy and patients who develop antibodies may have a lower chance of causing a pregnancy even when a successful vasectomy reversal allows sperm to re-enter the ejaculate. These antibodies have no influence on health status otherwise.

Late complications: 5. Hydrocele after vasectomy is rare. Hydrocele is fluid around the testicle. This condition is benign and usually doesn't cause symptoms. If the hydrocele fluid is bothersome, there are procedures to remove the fluid.

Late complications: 6. Tethering of the vas deferens is rare but can occur if one of the cut ends of the vas deferens heals too close to the scrotal skin. The tethered vas can cause a bothersome pulling sensation that may require an additional corrective procedure.

Late complications: 7. Sexual side effects . There are reports on the internet in which contributors claim that they experienced a decrease in erectile function, libido, or climax intensity after vasectomy. There is no physiological explanation for these changes, either positive or negative, but men should consider the slight possibility of a negative influence of vasectomy on their sexual responses. These changes may simply represent changes that would have otherwise occurred to these men over 6 months, regardless of whether they had a vasectomy or not. Men who don't want to take any chance that there could be an adverse influence of vasectomy on their sexual function should not have a vasectomy and should use an alternative for pregnancy prevention.

I understand that if I book my vasectomy and do not show up OR if I cancel my vasectomy with less than two business day's notice OR if I do something I was clearly instructed not to do (ie. Take ASA, NSAIDS or anticoagulants within the previous week) thereby requiring my surgery to be cancelled, I am required to pay a cancellation fee of $150.

I, the undersigned, request that Dr. Jay Buenafe or Dr. Karen Tanner perform a no scalpel vasectomy, a procedure to produce obstruction of the vas deferens for the purpose of producing sterility. I understand there can be no absolute guarantee that this or any procedure will be successful. It is understood, however, that my semen will be checked following the operation. I also understand that while the reversal success rate is quite good, it is not 100%, and vasectomy should therefore be considered a permanent or non-reversible procedure.*

By consenting to vasectomy and accepting the risks outlined above, I release them from liability for time lost from work, salary unearned, and medical expenses incurred to treat complications.*