Vasectomy Consent Form
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.
The English language resource was created or reviewed by a medical professional for quality and accuracy.
This translation was evaluated by a representative or group from the community for accuracy and cultural relevance.