AW Surgeries: Withymoor Surgery, Turners Lane, Brierley Hill, DY5 2PG

Dudley Community One Stop No Scalpel Vasectomy Service

Referral Form

Exclusions: The following categories of patients are not suitable for having their vasectomies done by the Community Service and should be referred to Urology:

. Patients with coagulation disorders or on anticoagulation therapy; . Patients with inguinal hernias; . Patients who request the procedure to be performed under general anaesthesia; . Patients who have had previous testicular surgery; . Morbidly obese patients; and . Patients with large varicoceles or large hydroceles.

The following patients should have the procedure delayed until the condition is evaluated and/ or corrected:

. Patients with local infections such as a scrotal skin infection, active STIs, balanitis, epididymitis or orchitis; . Systemic infection or gastroenteritis; and . Patients with intra-scrotal masses.

Date of Referral:

Patient Surname: Date of Birth:

Patient First Name: Ethnic Origin:

Full Address:

Home Telephone Number:

Mobile Number: NHS No:

Significant Medical History:

Current Medication:

Allergies:

Referred By: Practice:

Address:

Telephone: Fax:

Please fill out all the sections of this form as otherwise it may be returned.