<p> Dudley Community One Stop No Scalpel Vasectomy Service</p><p>Referral Form </p><p>Exclusions: The following categories of patients are not suitable for having their vasectomies done by the Community Service and should be referred to Urology:</p><p>. 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.</p><p>The following patients should have the procedure delayed until the condition is evaluated and/ or corrected:</p><p>. 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.</p><p>Date of Referral:</p><p>Patient Surname: Date of Birth:</p><p>Patient First Name: Ethnic Origin:</p><p>Full Address: </p><p>Home Telephone Number:</p><p>Mobile Number: NHS No: </p><p>Significant Medical History:</p><p>Current Medication: </p><p>Allergies:</p><p>Referred By: Practice:</p><p>Address:</p><p>Telephone: Fax: </p><p>Please fill out all the sections of this form as otherwise it may be returned. </p><p>Page 1 of 1</p>