Form Testing Booking Form July 2025 With Date Picker A form for users to book their vasectomy. "*" indicates required fields Snip clinic location*Select a locationAuckland – AvondaleAuckland – CentralAuckland – ManukauAuckland – RemueraAuckland – TakapunaChristchurchDunedinHamiltonInvercargillLower HuttMastertonNapierNelsonNew PlymouthPalmerston NorthQueenstownRotoruaTaurangaWellingtonWhangāreiThis field is hidden when viewing the formPlugin DateThis field is hidden when viewing the formPlugin TimeFull Legal Name* First Name Last Name Date of Birth* DD slash MM slash YYYY This field is hidden when viewing the formAge*What is your ethnicity?Please selectNZ EuropeanMāoriAfricanAmericanAustralianBritishCanadianChineseCook IslanderEuropeanFijianIndianJapaneseLatin AmericanMiddle EasternNiueanOtherOther AsianOther PasifikaTokelauanSamoanTonganPhone Number*Email Address* Street Address* Street Address Suburb Town/City Postcode This field is hidden when viewing the formWhat gender do you identify with?*Not applicableNot applicableThis field is hidden when viewing the formPlease state what gender you identify with*This field is hidden when viewing the formAdditional ethnicity?Not applicableNZ EuropeanMāoriAfricanAmericanAustralianBritishCanadianChineseCook IslanderEuropeanFijianIndianJapaneseLatin AmericanMiddle EasternNiueanOtherOther AsianOther PasifikaTokelauanSamoanTonganAre you registered with a Medical Centre?*Please selectYesNoName of Medical Centre*General Practitioner NameThe Ministry of Health is collecting stats on vasectomies. Would you be up for answering 3 quick questions?*Please selectYesNoRelationship status*Please selectIn a relationshipNot in a relationshipPrefer not to answerNumber of Children*Please select012345678910+Prefer not to answerReason for getting a vasectomy?*Please selectDecision not to have any more childrenHealth of myself and/or my partnerInheritable genetic conditionDecision to have no childrenOther (please specify)Prefer not to answerPlease provide further information for your reason to get a vasectomy*This field is hidden when viewing the formIs your partner currently pregnant?*Please selectYesNoPrefer not to answerThis field is hidden when viewing the formWhat is the due date of the baby?* DD slash MM slash YYYY We will send you written full information and a video about your procedure. However, if you would like to have a phone appointment, please indicate this below.Would you like to book a phone appointment with a nurse before your Snip to discuss the procedure and any other questions you have?*Please selectYesNoDo 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 Do you have any of the following medical conditions?* Diabetes Bleeding disorders Heart disease ICD/Pacemaker I don’t have any of the above medical conditions Are you allergic to any medication?*Please selectYes (please specify)NoWhat medication are you allergic to?*Would you like to take additional medication to help you feel calmer?*Temazepam is an oral tablet taken shortly before your procedure while Penthrox is a fast-acting inhaler (green whistle) used during your procedure. Learn more about these medications on our Managing Anxiety page Yes – I would like additional medication No – I don’t need additional medication What additional medication would you like?* Temazepam only – $35 Penthrox only – $295 Both Temazepam & Penthrox – $330 Since you’ve chosen Penthrox, you’ll need to have a quick chat with one of our nurses before your Snip. We’ll set up a phone appointment so they can walk you through a few important details.Pharmacy Details*Please provide your pharmacy name, address and phone numberHave you had any groin injuries or groin surgery?*For example: vasectomy reversal, twisted testicles, hydrocele, inguinal herniaPlease selectYes (please specify)NoDetails of groin injury or groin surgery*Based on what you’ve shared, it seems you’ll need to speak with one of our nurses before your Snip. We’ll set up a phone appointment for you, so the nurse can give you some specific information and share anything important with the doctor.This field is hidden when viewing the formPlease select any other ethnicities you identify with (2)NoneNZ EuropeanMāoriAfricanAmericanAustralianBritishCanadianChineseCook IslanderEuropeanFijianIndianJapaneseLatin AmericanMiddle EasternNiueanOtherOther AsianOther PasifikaTokelauanSamoanTonganThis field is hidden when viewing the formPlease select any other ethnicities you identify with (3)NoneNZ EuropeanMāoriAfricanAmericanAustralianBritishCanadianChineseCook IslanderEuropeanFijianIndianJapaneseLatin AmericanMiddle EasternNiueanOtherOther AsianOther PasifikaTokelauanSamoanTonganThis field is hidden when viewing the formPlease select any other ethnicities you identify with (4)NoneNZ EuropeanMāoriAfricanAmericanAustralianBritishCanadianChineseCook IslanderEuropeanFijianIndianJapaneseLatin AmericanMiddle EasternNiueanOtherOther AsianOther PasifikaTokelauanSamoanTonganThis field is hidden when viewing the formPlease select any other ethnicities you identify with (5)NoneNZ EuropeanMāoriAfricanAmericanAustralianBritishCanadianChineseCook IslanderEuropeanFijianIndianJapaneseLatin AmericanMiddle EasternNiueanOtherOther AsianOther PasifikaTokelauanSamoanTonganDo you have health insurance and who is your insurance provider?*Please selectNo insuranceYes – AccuroYes – AIAYes – AAYes – NIBYes – Partners LifeYes – Police Health PlanYes – Sovereign (now AIA)Yes – UniMedYes – Other insurance providerUnfortunately, we are not partnered with your insurance company. Please contact them directly to check if your policy covers vasectomy. If it does, you can submit an insurance claim to your provider after your procedure.Do you need a quote from us for your WINZ application?*Please selectYesNoWould you prefer to pay now or pay on the day?* Pay now Pay on the day Your vasectomy fee: $595 Total cost on the day: – Vasectomy only: $595 – Vasectomy + Temazepam: $630 – Vasectomy + Penthrox: $890 – Vasectomy + Temazepam + Penthrox: $925 Optional medication: • Temazepam: +$35 • Penthrox: +$295Vasectomy Fee* Price: Vasectomy Fee*including Temazepam ($35) Price: Vasectomy Fee*including Penthrox ($295) Price: Vasectomy Fee*including Temazepam & Penthrox ($330) Price: MessageI 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? and I understand the effects of testosterone therapy I have read and agree to Terms & Conditions* I agree Click here to see TermsThis field is hidden when viewing the formDoctorIDThis field is hidden when viewing the formDoctorNameThis field is hidden when viewing the formSlotID
