Test - Queensland

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Circumcision
Vasectomy
Frenuloplasty
Joint Procedure
Location

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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

Home Test

Test

Please enable JavaScript in your browser to complete this form.

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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 phone number

Age of Wife/ Partner

Wife/Partner aware of vasectomy?

Yes
No

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Children with partner

Total children

Partner's total children

Age of youngest child *

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?

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Hernia surgery as an infant or child? *

Yes
No

Hernia surgery as an adult? *

Yes
No

Surgery as a child for Undescended testes? *

Yes
No

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Surgery for torsion or twisted testes? *

Yes
No

Prior vasectomy or prior vasectomy reversal? *

Yes
No

Any other type of scrotal or testes surgery? *

Yes
No

Any other type of operations? *

Have you had any of these problems?

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Bleeding or easy bruising? *

Yes
No

Premature ejaculation? *

Yes
No

Difficult getting erection? *

Yes
No

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Tendency to faint or lightheadedness? *

Yes
No

Genital warts/herpes? *

Yes
No

Varicocele? *

Yes
No

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HIV? *

Yes
No

Epididymitis? *

Yes
No

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

Designed ©2024 by AB Agency.

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

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

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