Request a Vasectomy - Porthcawl Group Practice

Please complete the form below to request a vasectomy.

You may also find the NHS 111 Wales vasectomy overview useful before completing your request.

Surname

Forename(s)

Date Of Birth

For example, 15 3 1984

Day

Month

Year

Address

Postcode

Mobile Number

Email Address

Reason sterilisation required

Number of children

Age of youngest child

Height

Weight

Body Mass Index (MBI - if known)

Smoking Status

Current Contraception Used

Other contraception's considered and details of any intolerance

Please details any previous testicular history, other operations and relevant history

Current Medications

Known allergies

Any Other Comments

Is an interpreter required?

Yes

If yes, what language?