Bookings

Customer Name(Required)

First Name Last Name

Age(Required)

Date of Birth(Required)

Contact phone Number(Required)

Email Address(Required)

Address(Required)

Street Address Suburb Post Code

What would be your preferred date for your procedure?(Required)

Are you enrolled with a GP?*(Required)

Yes
No

What is the name of the Medical Centre?(Required)

What is the name of your GP?(Required)

Do you have health insurance?(Required)

Yes
No

What is the name of your Health Insurance provider?(Required)

Do you take any regular medications? If so please note them here(Required)

Are you allergic to any medication?(Required)

Yes - please specify
No

What medication are you allergic to?(Required)

Do you have any medical conditions? If so please note them here(Required)

Have you had any injuries or surgery in the groin area?(Required)

Yes - Please specify Below
No

Please provide us with further information regarding the injury or surgery(Required)

Have you had or do you have an inguinal hernia , or inguinal hernia operation?(Required)

Yes
No

Ethnicity

How many children do you have?(Required)

What ages are your children?(Required)

What type of work do you do?(Required)

Are you currently in a relationship?(Required)

In a relationship
Not in a relationship

Reason for getting a vasectomy?(Required)

Please provide further information for your reason to get a vasectomy(Required)

Is your partner pregnant?(Required)

Yes
No

When is the baby due?(Required)

Is there anything else we would need to know?

Note – please ensure you book your procedure when you have a quiet weekend planned.

Please note: we request a 50% deposit at time of booking. Payment details will be provided when booking is confirmed.

Making a booking

New Clinic open for bookings:

Kapiti Day Hospital

45B Te Roto Drive, Paraparaumu

and

Onslow Medical Centre

125 Moorefield Road Johnsonville

Bookings

Call today to book your vasectomy appointment

CONTACT US

Onslow Medical Centre

Kapiti Day Hospital

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