inquiry Vasectomy - Queensland

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Home
Circumcision
Vasectomy
Frenuloplasty
Joint Procedure
Location

Home
Circumcision
Vasectomy
Frenuloplasty
Joint Procedure
Location

Login

Home
Circumcision
Vasectomy
Frenuloplasty
Joint Procedure
Location

Inquiry Vasectomy

Please fill out this form

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Name *

Age

DOB

Phone number *

Email Address *

Address

Message

Contact

Phone: 0421 052 576
Business Hours: By appointment only - Main Location
ABN: 40625232028
Email address: info@qcv.au

Address

Doctors at Wellington Point
Address: Shop 21, Floor 1, 685 Old Cleveland Road East, Wellington Point, QLD Ph- (07)3106 1270
South Kempsey Medical Centre
Address: Suite 200, 35 Belgrave Street, Kempsey NSW 2440 Ph- (02) 7228 5898
Toowomba Hooper Medical Centre
Address: 187 Hume street, Toowoomba, QLD
Ph- (07) 4613 0500

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Please fill out this form for a same day consult and vasectomy procedure

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Layout

Name *

Address *

Age *

Phone number *

DOB *

Email address *

Marital status? *

Single
Having a Wife/Partner

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Wife/Partner's name

Wife/Partner aware of vasectomy?

Yes
No

Wife/Partner phone number

Age of Wife/ Partner

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Children with partner

Total children

Partner's total children

Age of youngest child *

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Partner/Wife pregnant now? *

Yes
No

Contraception/Birth control method past few months *

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Any regular medications? *

Yes
No

Any blood thinners? *

Yes
No

Allergy to any medication? *

Yes
No

Medication name

Have you had any of the following?

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Hernia surgery as an infant or child? *

Yes
No

Surgery for torsion or twisted testes? *

Yes
No

Hernia surgery as an adult? *

Yes
No

Prior vasectomy or prior vasectomy reversal? *

Yes
No

Surgery as a child for Undescended testes? *

Yes
No

Any other type of scrotal or testes surgery? *

Yes
No

Any other type of operations? *

Have you had any of these problems?

Layout

Bleeding or easy bruising? *

Yes
No

Tendency to faint or lightheadedness? *

Yes
No

Premature ejaculation? *

Yes
No

Genital warts/herpes? *

Yes
No

Difficult getting erection? *

Yes
No

Varicocele? *

Yes
No

Layout

HIV? *

Yes
No

Epididymitis? *

Yes
No

Message

Please enable JavaScript in your browser to complete this form.

Layout

Name *

Address *

Age *

Phone number *

DOB *

Email address *

Marital status? *

Single
Having a Wife/Partner

Layout

Wife/Partner's name

Wife/Partner aware of vasectomy?

Yes
No

Wife/Partner phone number

Age of Wife/ Partner

Layout

Children with partner

Total children

Partner's total children

Age of youngest child *

Layout

Partner/Wife pregnant now? *

Yes
No

Contraception/Birth control method past few months *

Layout

Any regular medications? *

Yes
No

Any blood thinners? *

Yes
No

Allergy to any medication? *

Yes
No

Medication name

Have you had any of the following?

Layout

Hernia surgery as an infant or child? *

Yes
No

Surgery for torsion or twisted testes? *

Yes
No

Hernia surgery as an adult? *

Yes
No

Prior vasectomy or prior vasectomy reversal? *

Yes
No

Surgery as a child for Undescended testes? *

Yes
No

Any other type of scrotal or testes surgery? *

Yes
No

Any other type of operations? *

Have you had any of these problems?

Layout

Bleeding or easy bruising? *

Yes
No

Tendency to faint or lightheadedness? *

Yes
No

Premature ejaculation? *

Yes
No

Genital warts/herpes? *

Yes
No

Difficult getting erection? *

Yes
No

Varicocele? *

Yes
No

Layout

HIV? *

Yes
No

Epididymitis? *

Yes
No

Message