Book your Vasectomy With NZ's Leading Provider

SNIP location*

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Preferred time*

Date of Birth*

Age*

Phone Number*

Email Address*

What gender do you identify with?*

Please state what gender you identify with*

What is your primary ethnicity?*

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 injuries or surgery in the groin area?*

Details of groin injury or surgery to the groin*

Would you like us to schedule a nurse consultation for you? At this consultation the nurse will go through the procedure and consent form with you and answer any questions you might 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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