I ………………………………………………………… D.o.B ……………………………………………………………
consent to undergo the operation of Vasectomy under local anaesthetic, the nature and purpose of which has been explained to me by Dr. William Lynch. I confirm I have read and understood the explanatory leaflet and instruction sheet supplied by Enniscorthy Medical Centre.
I have been told that the intention of the operation is to make me permanently sterile but that there is a low failure rate.
I understand that I must supply a sample at 16 weeks after the procedure to confirm my sterility. Until this has been confirmed by letter, my partner and I must continue to use a method of contraception.
I have been warned that the operation has a low complication rate and is usually due to bleeding, infection or scar tissue. Cases of persistent scrotal discomfort after vasectomy have been reported but most are mild and settle without treatment.
Date ………………. Signed ………………………………….. (Patient)
Date ………………. Signed …………………………………. (Wife/Partner)
I confirm that I have explained to the patient the nature and purpose of this operation
Date ………………. Signed …………………………………. (Dr. William Lynch)
.
Whitemill Medical Centre,