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SNIP 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*

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*

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*

What is your ethnicity?*

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Additional ethnicity?

Relationship status*

Number of Children*

Reason for getting a vasectomy?*

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

Is your partner currently pregnant?*

What is the due date of the baby?*

Are you registered with a Medical Centre?*

General Practitioner Name

Name of Medical Centre*

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*

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

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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?*

Do you need a quote from us for your WINZ application?*

Service Fee*

Price:

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