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Vasectomy Protocol

Your Name (required)

Your Date of Birth (required)

Your Address (required)


Your Telephone number - preferably mobile. (required)

Your Occupation

GMS number (if applicable)

Name of GP

Your Medical history


Allergies to any medication

Current medication

As an adult, are you prone to fainting, especially with medical procedures

Have you ever had any problems with either testicle?

Number of children.

Age of wife/partner

Your Email

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