I authorize ___________________, M.D.,. to perform a bilateral vasectomy on me.
I understand this procedure will include removal
of a small portion of each vas through a scrotal incision and then sealing the
severed ends.
I understand that this procedure is being performed
in an attempt to achieve permanent sterility.
I give consent for the use of an appropriate
anesthetic agent and for possible evaluation of any removed tissue by a
pathologist.
I understand that with vasectomy a small
percentage of patients will develop complications. Among the more common
problems are infection, bleeding, pain (short or long term, from known or
unknown causes), sperm granuloma (
a painful bump at the site of the vasectomy), and epididymitis
(inflammation or infection of part of the sperm duct system requiring
antibiotics and pain medication). Any complication may require further
treatment which may include medications, hospitalization and even surgery. Recanalization
or re-joining of the vas ends may occur spontaneously in a small percentage of
cases creating a situation in which sterility is not achieved. This condition
may necessitate a repeat vasectomy.
I understand that I am not to be considered
sterile until two consecutive post-operative sperm analyses have confirmed the
absence of sperm. I understand that
contraception must be used until I have been told by this office that no sperm
were present on these specimens.
I understand that the chance of delayed recanalization
after two negative semen checks is astronomically small.
I understand that the long term effects of
vasectomy have been studied extensively. To date, no known diseases have been
proven to be caused by vasectomy in humans including prostate cancer or
dementia.
I understand that I expect to be sterile as a result of this operation, although no such result is warranted or guaranteed. I understand what the term sterility means and in giving my consent to the vasectomy, I have in mind the probability of such a result.
SIGNED___________________________________________DATE_______________
(Patient)
SPOUSE CONSENT TO VASECTOMY
I join in authorizing the performance of a vasectomy upon my husband. It has been explained to me that as a result of the operation my husband may be sterile. This fact must be confirmed by post vasectomy sperm analyses.
SIGNED___________________________________________DATE_______________
(Spouse)