First name* Last name* Age* Date of birth* Phone number* Email Address* Street Address* Suburb* Preferred SNIP location* Preferred SNIP location*Auckland | CentralAuckland | HendersonAuckland | ManukauAuckland | RemueraAuckland | TakapunaChristchurchGisborneHamiltonInvercargillLower HuttMastertonNapierNelsonNew PlymouthPalmerston NorthTaurangaWellington Preferred date* Preferred date*Thursday, 18 August 2022Friday, 26 August 2022Thursday, 8 September 2022Friday, 16 September 2022Thursday, 1 December 2022Friday, 9 December 2022Thursday, 22 December 2022 Preferred date* Preferred date*Thursday, 1 September 2022Thursday, 15 September 2022Thursday, 29 September 2022Thursday, 13 October 2022Thursday, 27 October 2022Thursday, 10 November 2022Thursday, 24 November 2022Thursday, 8 December 2022Thursday, 22 December 2022 Preferred date* Preferred date*Thursday, 25 August 2022Friday, 2 September 2022Friday, 16 September 2022Friday, 11 November 2022Friday, 9 December 2022 Preferred date* Preferred date*Friday, 2 September 2022Friday, 9 September 2022Friday, 23 September 2022Friday, 2 December 2022Friday, 16 December 2022Friday, 23 December 2022 Preferred date* Preferred date*Thursday, 1 September 2022Thursday, 15 September 2022Thursday, 22 September 2022Thursday, 8 December 2022Thursday, 15 December 2022 Preferred date* Preferred date*Wednesday, 10 August 2022Thursday, 20 October 2022Wednesday, 2 November 2022Wednesday, 30 November 2022Thursday, 8 December 2022 Preferred date* Preferred date*5 October 2022 Preferred date* Preferred date*Wednesday, 17 August 2022Wednesday, 21 September 2022Wednesday, 19 October 2022Wednesday, 16 November 2022Wednesday, 14 December 2022 Preferred date* Preferred date*Friday, 30 September 2022Thursday, 3 November 2022Thursday, 1 December 2022 Preferred date* Preferred date*Friday, 9 September 2022Friday, 21 October 2022Friday, 18 November 2022Friday, 2 December 2022 Preferred date* Preferred date*Monday, 19 September 2022Monday, 28 November 2022 Preferred date* Preferred date*Thursday, 6 October 2022Thursday, 10 November 2022Thursday, 15 December 2022 Preferred date* Preferred date*Thursday, 11 August 2022Wednesday, 24 August 2022 Preferred date* Preferred date*Wednesday, 7 September 2022Wednesday, 21 September 2022Wednesday, 5 October 2022Wednesday, 9 November 2022Wednesday, 19 October 2022Wednesday, 23 November 2022Wednesday, 7 December 2022 Preferred date* Preferred date*Friday, 9 September 2022Friday, 23 September 2022Friday, 7 October 2022Friday, 21 October 2022Friday, 4 November 2022Friday, 18 November 2022Friday, 2 December 2022Friday, 16 December 2022 Preferred date* Preferred date*Friday, 12 August 2022Friday, 19 August 2022Friday, 2 September 2022Friday, 9 September 2022Friday, 16 September 2022Friday, 23 September 2022Friday, 30 September 2022Friday, 7 October 2022Friday, 14 October 2022Friday, 21 October 2022Friday, 28 October 2022Friday, 4 November 2022Friday, 11 November 2022Friday, 18 November 2022Friday, 25 November 2022Friday, 2 December 2022Friday, 9 December 2022Friday, 16 December 2022 Preferred date* Preferred date*Wednesday, 21 September 2022Friday, 28 October 2022Friday, 25 November 2022Friday, 16 December 2022 Are you enrolled with a GP?* Are you enrolled with a GP?* Yes No Medical Centre Name* Name of GP* Do you have Health Insurance?* Do you have Health Insurance?* Yes No Name of Health Insurance provider* Do you take any of the following medications?* Do you take any of the following medications?* Anabolic steroids Aspirin Blood thinners Immunosuppressants Oral steroids Testosterone therapy I do not take any of the above medication Are you allergic to any medication?* Are you allergic to any medication?*Yes - Please specifyNo What medication are you allergic to?* Do you have any of the following medical conditions?* Do you have any of the following medical conditions?* Diabetes Bleeding disorders Heart disease I don't have any of the above medical conditions Have you had any injuries or surgery in the groin area?* Have you had any injuries or surgery in the groin area?*Yes - Please specifyNo Please provide further information regarding the injury or surgery ethnicity ethnicityNZ EuropeanMāoriAfricanAmericanAustralianBritishCanadianChineseCook IslanderEuropeanFijianIndianJapaneseLatin AmericanMiddle EasternNiueanOtherOther AsianOther PasifikaTokelauanSamoanTongan Number of Children* Number of Children*012345678910+ Relationship status?* Relationship status?*In a relationshipNot in a relationship Reason for getting a vasectomy* Reason for getting a vasectomy*Decision not to have anymore childrenHealth of myself and/or my partnerInheritable genetic conditionOther - Please Specify Please provide further information for your reason to get a vasectomy* Current method of contraception* Current method of contraception*My partner has an IUDMy partner uses the rod or the injections (Jadelle or Depo)My partner is on the pillCondomsPull-out methodNo contraception Is your partner currently pregnant?* Is your partner currently pregnant?*YesNo What is the due date of the baby?* Covid-19 vaccination status* Covid-19 vaccination status*Fully VaccinatedPartly Vaccinated (1 dose)UnvaccinatedI would prefer not to say Is your vaccination status likely to change before your appointment?* Is your vaccination status likely to change before your appointment?*YesNo Message We will send you video links and information about your procedure prior to your appointment. In addition to this would you like a nurse phone consultation prior to your appointment*? We will send you video links and information about your procedure prior to your appointment. In addition to this would you like a nurse phone consultation prior to your appointment*? Yes, I would like a phone consultation with the nurse No, I don't wish to speak with the nurse I understand the effects testosterone therapy has on the ability to confirm infertility at the 3-month clearance test* I understand the effects testosterone therapy has on the ability to confirm infertility at the 3-month clearance test* I have read the information about "What if I am on testosterone?" I understand the effects of testosterone therapy I have read and agree to Terms & Conditions* I have read and agree to Terms & Conditions* I agree Click here to see Terms Submit
