Booking Form Test

Snip clinic location*

Auckland Avondale - Booking date*

Auckland Central - Booking date*

Auckland Manukau - Booking date*

Auckland Remuera - Booking date*

Auckland Takapuna - Booking date*

Christchurch - Booking date*

Dunedin - Booking date*

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Gisborne - Booking date*

Hamilton - Booking date*

Invercargill - Booking date*

Lower Hutt - Booking date*

Masterton - Booking date*

Napier - Booking date*

Nelson - Booking date*

New Plymouth - Booking date*

Palmerston North - Booking date*

Queenstown - Booking date*

Rotorua - Booking date*

Tauranga - Booking date*

Wellington - Booking date*

Whangarei - Booking date*

Preferred time*

Date of Birth*

Age*

What is your ethnicity?

Phone Number*

Email Address*

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What gender do you identify with?*

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Please state what gender you identify with*

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Additional ethnicity?

Are you registered with a Medical Centre?*

Name of Medical Centre*

General Practitioner Name

The Ministry of Health is collecting stats on vasectomies. Would you be up for answering 3 quick questions?*

Relationship status*

Number of Children*

Reason for getting a vasectomy?*

Please provide further information for your reason to get a vasectomy*

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Is your partner currently pregnant?*

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What is the due date of the baby?*

Would you like to book a phone appointment with a nurse before your Snip to discuss the procedure and any other questions you have?*

Are you allergic to any medication?*

What medication are you allergic to?*

Have you had any groin injuries or groin surgery?*

For example: vasectomy reversal, twisted testicles, hydrocele, inguinal hernia

Details 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.

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Please select any other ethnicities you identify with (2)

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Please select any other ethnicities you identify with (3)

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Please select any other ethnicities you identify with (4)

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Please select any other ethnicities you identify with (5)

Do you have insurance and who is your insurance provider?*

Unfortunately, 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?*

Service Fee*

Price:

Message

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Booking Form 2.0 With autocomplete addresses

Ready to be book?