SimpleVas® Registration Form

10. SimpleVas® VASECTOMY SURGICAL CONSENT

1. Vasectomy is a PERMANENT method of contraception. The objective is to prevent sperm from entering the semen by means of interrupting the communication between the testicles and the rest of the genital system responsible for semen production. It has been quoted to me that it bears over 99% chances of being successful in its objective.*

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2. REGRET after a vasectomy is a possibility, therefore I understand it is a PERMANENT and NON-REVERSIBLE procedure because vasectomy reversals are not always successful.*

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3. After the vasectomy, the portions of the vas tubes within the pelvis still contain live sperm until they are all released. About 98% of men are SPERM-FREE AFTER 20 ejaculations and 12 weeks.*

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4. In 5% of men, the semen may still contain some sperm (usually few in number and not active) for months, so it is important to have a SEMEN SAMPLE CHECKED and to use other forms of birth control UNTIL IT IS CONFIRMED by microscopic examination that the semen is SPERM-FREE.*

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5. BLEEDING can occur DURING or AFTER vasectomy. If this occurs within the scrotum, drainage of a scrotal hematoma (blood clot) in a hospital operating room could be necessary. Smaller hematomas do not require surgical drainage, but tender swelling can last for 2 to 4 weeks. Both large and small hematomas are very RARE. If the scrotal skin bleeds at the vasectomy access site, the scrotum can become DISCOLORED (black and blue) for about a week; this is more common than swelling, but painless.*

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6. INFECTION is a RARE complication of a vasectomy. The rate is exceedingly low, but if present it may lead to administration of antibiotics.*

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7. SPERM GRANULOMA is a pea-sized (sometimes tender) lump on the vas tube at the vasectomy site, almost never requiring treatment. Some consider sperm granulomas beneficial, as they may increase the likelihood of success with vasectomy reversal. Periodic tenderness usually responds to an anti-inflammatory medication like ibuprofen.*

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8. CONGESTION, tender buildup of sperm and white blood cells upstream from or at the vasectomy site, can occur any time after vasectomy, but usually goes away with use of an anti- inflammatory drug such as ibuprofen. About 1 in 2000 patients will experience chronic post- vasectomy discomfort (PVPS or Post-Vasectomy Pain Syndrome) severe enough that he will seek vasectomy reversal.*

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9. RECANALIZATION is the development of a channel for sperm flow between the two cut ends of the vas. If this happens during the healing process (early), the semen never becomes sperm-free until the vasectomy is repeated. If recanalization happens late (months or years after a man's semen has been examined and declared sperm-free), an unplanned pregnancy could result; but the odds of this occurring is far less after vasectomy than the odds of pregnancy with any other form of birth control including birth control pills and tubal ligation (female sterilization).*

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10. There are NO PROVEN LONG-TERM HEALTH RISKS (neither cancer nor cardiovascular disease) associated with vasectomy based on current medical research.*

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11. There are ALTERNATIVES to vasectomy including barrier methods for men and women, hormonal methods for women, and the IUD; all of which are REVERSIBLE..*

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12. I request that ESGAR GUARIN, MD perform a BILATERAL VASECTOMY. I understand that there can be NO ABSOLIUTE guarantee that this or any procedure will be successful. It is understood, however, that my semen will be checked following the operation. By consenting to vasectomy and accepting the risks outlined above, I release Dr. GUARIN and the places where he performs his vasectomy procedure from any liability for time lost from work, salary unearned, and medical expenses incurred to treat complications. I have read, and I understand, all paragraphs of this document. I understand that a deposit/partial payment may be required prior to scheduling the procedure.*

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13. DEPOSIT POLICY: • $99 deposit is REQUIRED prior to final scheduling of your procedure.• Deposit is FULLY REFUNDABLE UNTIL 7 calendar days prior to the appointed vasectomy date. • Deposit WILL NOT be refunded thereafter for either cancellation or postponement (special circumstances will be considered to keep the deposit for a future date) • Deposit will be REIMBURSED at the time of service for those using insurance, UNLESS coverage is insufficient (for use of co-pay, or high deductible) • Deposit will be APPLIED to cost of vasectomy for those opting out of using insurance*

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Electronic signature (type full name)*

Date of completion of form and consent*

PRIVACY POLICY
DISCLAIMER

REVIEW THESE INSTRUCTIONS BEFORE SURGERY

Date of vasectomy

Post-vasectomy issues

Yes
No
Unable to contact

Vasectomy complications

Other complications

PVSA (initial at ≥12w)

Negative
≤ 100,000 non-motile sperm
> 100,000 non-motile / motile sperm
Not completed

REGISTRATION FORM

SimpleVas® Registration

Step 1 of 8

1. PERSONAL INFORMATION

2. INSURANCE INFORMATION

3. EMPLOYMENT INFORMATION

4. VASECTOMY LOCATION AND DATE PREFERENCES

5. HEALTH INFORMATION

6. PRIMARY CARE DOCTOR INFORMATION

7. FAMILY INFORMATION

8. REFERRAL INFORMATION

9. PREPARATION FOR SimpleVas® VASECTOMY (review information at www.simplevas.net)

10. SimpleVas® VASECTOMY SURGICAL CONSENT

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