Booking Form

First name*

Last name*

Age*

Date of birth*

Phone number*

Email Address*

Street Address*

Suburb*

Preferred SNIP location* Preferred SNIP location*Auckland | AvondaleAuckland | CentralAuckland | ManukauAuckland | RemueraAuckland | TakapunaChristchurchDunedinGisborneHamiltonInvercargillLower HuttMastertonNapierNelsonNew PlymouthPalmerston NorthQueenstownRotoruaTaurangaWellingtonWhangārei

Preferred date* Preferred date*Thursday, 21 December 2023Enquire for a 2024 date

Preferred date* Preferred date*Enquire for a 2024 date

Preferred date* Preferred date*Enquire for a 2024 date

Preferred date* Preferred date*Enquire for a 2024 date

Preferred date* Preferred date*Enquire for a 2024 date

Preferred date* Preferred date*Friday, 15 December 2023Enquire for a 2024 date

Preferred date* Preferred date*Thursday, 21 December 2023Enquire for a 2024 date

Preferred date* Preferred date*Enquire for a 2024 date

Preferred date* Preferred date*Enquire for a 2024 date

Preferred date* Preferred date*Enquire for a 2024 date

Preferred date* Preferred date*Enquire for a 2024 date

Preferred date* Preferred date*Enquire for a 2024 date

Preferred date* Preferred date*Enquire for a 2024 date

Preferred date* Preferred date*Enquire for a 2024 date

Preferred date* Preferred date*Wednesday, 13 December 2023Enquire for a 2024 date

Preferred date* Preferred date*Wednesday, 13 December 2023Enquire for a 2024 date

Preferred date* Preferred date*Enquire for a 2024 date

Preferred date* Preferred date*Enquire for a 2024 date

Preferred date* Preferred date*Enquire for a 2024 date

Preferred date* Preferred date*Friday, 15 December 2023Monday, 18 December 2023Enquire for a 2024 date

Preferred date* Preferred date*Thursday, 14 December 2023Enquire for a 2024 date

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

Details of groin injury or surgery to the groin:

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*

Is your partner currently pregnant?* Is your partner currently pregnant?*YesNo

What is the due date of the baby?*

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