Vasectomy Consent

Consent for bilateral vasectomy

I hereby authorize David Robbins, M.D. and any assistants as may be selected by said physician to treat the following condition(s):

FERTILE MALE DESIRING STERILIZATION

The procedure planned for the treatment of my condition(s) have been explained to me by my physician and are listed below:

DIVISION OF VAS FROM BOTH SIDES (BILATERAL VASECTOMY)

I understand the risks, benefits and alternative to the above bilateral vasectomy procedure. I have read and understand the patient information about vasectomy, including the American Urological Association (AUA) Vasectomy Guideline (2026) (opens in a new tab).

I understand that any aspect of this consent form that I do not understand can be explained to me in further detail by asking my physician(s) or their associates.

I certify that my physician has informed me that the nature and character or the proposed treatment, or the anticipated results of the proposed treatment, or the possible alternative forms of treatment; and the recognized serious possible risk, complications, and anticipated benefits involved in the proposed treatment and the alternative forms of treatment, including non treatment.

I certify that I have read this consent and all my questions have been answered. I certify that I have not taken any aspirin or any blood thinners within two weeks of this procedure.

At your appointment you, a witness and Dr. Robbins sign this form. Dr. Robbins also confirms in writing that he explained the procedure, its risks, the alternatives (including no treatment) and the expected results before you consented.

More patient information about vasectomy is available from the Urology Care Foundation (opens in a new tab), the American Urological Association’s patient foundation. After the procedure, follow your vasectomy discharge instructions.