John J Bauer, MD, FACS John J. Bauer, M.D.
www.flinturology.com

Urology Services, Inc.
G-1121 West Hill Rd.
Flint, Michigan 48507
Tel: 810.232.8888
Fax: 810.232.9190
Email: jbauer@flinturology.com
[map]




Counseling and Pre-Op Note

Patient Name:

Age:

Date:

Procedure: Vasectomy

Indications:

Patient is a male that wishes to be sterilized; he has been counseled regarding the permanence of this procedure and a chance that even reversal at a later date may not restore fertility. Pt has a stable marital arrangement and is finished having children.

Alternatives:

Alternatives are standard birth control measures for both sex partners.

Risks/Complications:

The risks and complications of the procedure where extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures including the testicular artery which may result in atrophy or loss of the testicle, chronic epididymal and testicular pain which may be relieved by reversal of the vasectomy and recannalization in the future. Patient is aware that he must continue to use contraception until he has ejaculated 20 or more times and has a negative semen analysis confirming ?no sperm seen? if the procedure fails a pregnancy can result and additional procedures may be necessary. If the patient decides in the future that a reversal of the vasectomy is desired there may be a 10-20% chance he will not become fertile again. However, a biological child can still be obtained using artificial reproductive techniques at considerable cost to the patient.

You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.

Physician's Signature: ________________________________ Date: __________________

Patient Signature: __________________________________ Date: __________________

Witness: __________________________________