Note: The form should be submitted at least a day before the procedure

I hereby give consent for my vasectomy procedure.

a) I have decided to undergo the procedure on my own without any outside pressure, inducement or force.

b) I am aware that other methods of contraception are available to me. I know that for all practical purposes this procedure is permanent. I also know that there are still some chances of failure of the procedure for which the Doctor and the health facility will not be held responsible by me or by my relatives or by any other persons whatsoever.

c) I am aware that I am undergoing a medical procedure that carries an element of risk

d) The eligibility criteria for the procedure has been explained to me and I affirm that I am eligible to undergo the procedure under the criteria.

e) I agree to undergo the procedure under local anesthesia that the Doctor/health facility thinks suitable for me and to be given other medicines as considered appropriate by the doctor.

f) If after the procedure my spouse misses her periods then my spouse will report within 2 weeks to the doctor to discuss available options.

g) I agree to come for follow up visits to the hospital failing which I shall be responsible for the consequences if any.

h) I understand that vasectomy does not result in immediate azoospermia (lack of sperms in the semen) I agree to come for semen analysis 3 months after the procedure to confirm the success of the procedure failing which I shall be responsible for the consequences if any.

Your Name (required)

Your Email (required)

Box Address (*)

What is you Age?

Name of Spouse

How many living children (Male)?

How many Female living Children?

Religion

Education

Business Ocupation

Operating Centre (*)

Signature (*): I have read ALL of the above information and it has been explained to me that this form has the authority of a legal document https://www.wispivas.com/ . Call (+254) 721547978 if you need help

ACCEPTNOT ACCEPTED