quick vasectomy appointment Edmonton Canada clinic
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Vasectomy Registration

Please go ahead and complete the short registration form below. This will save you some paperwork later and permit us to get your booking processed right away. We will call you to schedule your appointment as soon as we get your registration.

If you have not already done so, please see the Vasectomy Fees page for detail on our optional Premium Vasectomy package. The Premium Package includes no-needle anaesthesia, your aftercare supply kit, and telephone follow-up instead of additional clinic visits after your procedure.

Out-of-town patients living more than one hour away will need a referral from a family doctor or walk-in clinic. Once received, we can book the consultation and procedure together to reduce travel.

This field is for validation purposes and should be left unchanged.

Patient Information

Name(Required)
Address(Required)
Type "N/A" if none
Emergency Contact Name(Required)
How did you hear about us?(Required)

Referring Doctor

Referring Doctor's Name
Referring Doctor's City

Family Doctor (If different from referring doctor)

Family Doctor's Name
Family Doctor's City

Family Information

What is your current relationship status?
Do you have children together?(Required)
Type "N/A" if none
Do you have children from a previous relationship?(Required)
Type "N/A" if none
Is your partner currently pregnant?(Required)

Contraception

What method(s) of contraception do you use?(Required)

Medical History

Please check any of the following that apply to you: (Please tick all that applies)(Required)

Surgical History

Please check if you have had any of the following:(Required)

Medications

Type "N/A" if none

Allergies

Type "N/A" if none

Sperm Storage

Will you be storing sperm?(Required)

Premium Service

Will you be choosing Premium Service? (Strongly Recommended) – Includes: NO-NEEDLE ANAESTHESIA for your comfort, ALL AFTERCARE SUPPLIES to save you time, FOLLOW-UPS BY PHONE, so you don’t have to travel back to the clinic.(Required)
Please see the Vasectomy Fees page for more detail on this $350 optional non-insured service.

Vasectomy Agreement

You must consent to the following:
(Required)
(Required)
(Required)
(Required)
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