Vasectomy Consent Form

Resource Properties

Abstract:

This one-page document is a consent form for providers to use with patients who are requesting a no-scalpel vasectomy (NSV) for male sterilization. The consent form provides a checklist of important information for patients to read and check off to indicate their understanding before having the procedure. It describes the procedure, including use of local anesthesia with Lidocaine, how long it takes for the procedure to work, its effectiveness, and permanence. It discusses possible risks, side effects, and the possibility of birth control failure. The form includes a place for the patient and a witness to sign and date, to show the patient's understanding and to release the provider from liability for any expenses incurred to treat complications.

Author(s):
Reproductive Health Access Project
Medical Review:
Yes
The English language resource was created or reviewed by a medical professional for quality and accuracy.
Development Method:
Translation from English text
Translation Review:
Community review
This translation was evaluated by a representative or group from the community for accuracy and cultural relevance.
Country:
N/A
Population:
N/A
Keywords:
Consent forms, Contraception, Men's Health, Reproductive sterilization, Vasectomy
Copyright:
Licensed by Creative Commons
Date Last Reviewed:
11/26/2014
Reviewed By:
Author/Agency

Access Resource

Language
Document
Video
Audio
English
Document: Open (PDF, 75.07 KB)
Video:
Audio:
Chinese, Simplified
Document: Open (PDF, 184.39 KB)
Video:
Audio:
Chinese, Traditional
Document: Open (PDF, 92.54 KB)
Video:
Audio: