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VASECTOMY -- Consent Form Version of Handout [En español] I, ____________________________________, authorize Dr. Kelly Locke and his designated assistant(s) to do a VASECTOMY, which consists of the surgical removal of a segment of both vas deferens (the tubes that convey sperm from the testicles to the outside). Other methods of treatment, including not having this procedure done, have been discussed with me and I have chosen the vasectomy method. I understand the following:
I have had an opportunity to ask questions and have them answered. In addition, I have read this form and it has been explained to me in lay terminology. I understand the risks and intend to have the vasectomy procedure done. Date __________ Signature of Patient Requesting Vasectomy_______________________________ Date __________ Witness _______________________________________________________
PHYSICIAN'S STATEMENT: The patient and I have discussed this procedure, the risks, complications, and alternatives. To the best of my knowledge, the patient understands the procedure and consents to it. (Physician's signature) ___________________________________ Date ______________________ Form based upon: COPIC Recommended Consent Form at http://www.copic.com/guidance/consent_forms/consent_vasectomy.htm Pfenninger: Procedures for Primary Care Physicians, 1st ed., Copyright © 1994 Mosby-Year Book, Inc.
Updated: 24 March 2001 |
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