One of the challenges in starting a vasectomy practice is writing the various forms you will need. Below we have examples of patient history forms, consents, operative notes, post-op instructions, etc. Feel free to modify these to suit your own practice.
History and registration form in English
(PDF format)
History and registration form in Spanish
(PDF format)
Vasectomy Consent Form
(PDF format)
Vasectomy Procedure Note
in English
(PDF format)
Vasectomy Procedure Note
in Spanish
(PDF format)
Vasectomy Procedure Note
for Dr. Stein and Dr. Curington. This is very specific to the physicians, and gives and example of a one-page complete op note. (PDF format)
Vasectomy Patient Information Worksheet (PDF). This form helps an assistant do very complete counseling. If an assistant just marches down the checklist and uses the diagrams, they will have done a thorough job in counseling.
Instructions for after vasectomy (PDF). A very generalized post-op instruction sheet.
Instructions for after vasectomy in (in website format). This is a link to aftercare instructions that we send by text to patients after a vasectomy. Many patients enjoy reading the instructions on their phones or tablets, and if they lose their paper instructions, it’s easy for us to send a link to the online version. Click here for English, here for Spanish, here for Portuguese.
Checklist for a Mobile Clinic.
This checklist is useful to pack a vehicle in preparation for traveling to do vasectomies. Of course modify this checklist to suit your own needs. (Word format)
Checklist for Setting up a Small Suitcase.
This checklist is useful to organize a small suitcase for doing up to 10 vasectomies. Of course modify this checklist to suit your own needs. (Excel format)
Checklist for Organizing a Vasectomy Training Session with Several Hundred Patients.
This checklist is useful to organize a large training mission during which you might see a few hundred patients. Of course modify this checklist to suit your own needs. (Excel format)
Inventory List for a Vasectomy Office.
This checklist is useful to do inventory in a vasectomy office. Of course modify this checklist to suit your own needs. (Excel format)