Book an appointment - Dr Bercier

CONTACT ONE OF OUR CLINICS

PERSONAL INFORMATION

OCCUPATION

Level of exertion at work

PHYSICIAN INFORMATION

Family

Marital Status

If you have a partner, is she aware that you are taking an appointment for a vasectomy?

My partner is pregnant.

What method of birth control are you using now?

FAMILY HISTORY

Does your child have any family history of bleeding disorders (e.g., hemophilia)?

MEDICAL HISTORY

Have you ever been diagnosed with any medical conditions?

Do you take prescription medications?

Do you take non-prescription drugs (aspirin)?

Are you allergic to any medications?

Do you have any bleeding problems?

Have you ever fainted or do you get queasy/faint with medical things like a blood test?

Have you ever had surgery to the scrotum or testicles including, but not limited to vasectomy, undescended testicles, torsion of the testicles, hydrocoele, varicocoele, hernia repair in childhood, tumor/cyst,growth in the scrotum or removal of a testicle?

Have you ever had genital herpes or genital warts?

Have you ever had a disease that can be transmitted by blood including, but not limited to, hepatitis or AIDS?

Have you ever had pain in the scrotum due to epididymitis or other cause?

MEDICAL HISTORY

Have you ever been diagnosed with any medical conditions?

Do you take prescription medications?

Do you take non-prescription drugs (aspirin)?

Are you allergic to any medications?

Do you have any bleeding problems?

Have you ever fainted or do you get queasy/faint with medical things like a blood test?

Have you ever had genital herpes or genital warts?

Have you ever had a disease that can be transmitted by blood including, but not limited to, hepatitis or AIDS?

Have you ever had pain in the scrotum due to epididymitis or other cause?

MEDICAL HISTORY

Has your child ever been diagnosed with any medical conditions such as bleeding disorders, hypospadias, or methemoglobinemia?

Does your child take any prescription medications (sulfonamides)?

Does your child take any non-prescription drugs (aspirin)?

Is your child allergic to any medications (e.g., lidocaine, prilocaine)?

Has your child ever undergone a surgery on the genital area?

Has your child ever been diagnosed with a blood transmitted disease including, but not limited to, AIDS?

CONSENT

* I have read and understand the four steps in family planning for this site.

* I am aware of the restrictions on physical activity for the week following the vasectomy.

* I confirm that I am the patient whose name appears in the personal information above and that I am filling this registration for myself and not for a husband or partner.

* I, undersigned, ask Dr. Jean-Philippe Bercier to perform a bilateral vasectomy on me, a procedure of obstruction of my vas deferens to make me sterile. I understand there is no absolute guarantee that this procedure or any other will be a success. However, I understand that my sperm will have to be analyzed after the operation. I also understand that I will need to use another form of contraception until there is no trace of spermatozoa left in my semen. Although I realize that the success rate of vasectomy reversals is good, it is not 100%. I must consider my vasectomy as a permanent and irreversible means of contraception. I also understand that there is a very small chance I may need to go to Dr. Bercier’s office or to the hospital for evaluation or treatment should there be a rather rare complication. By consenting to a vasectomy and accepting the risks described above, I discharge Dr. Bercier of any responsibility in terms of time lost at my work, salary not earned or any other medical expense related to treating a complication.

Consent

* I confirm that I am the parent/legal guardian of the child whose name appears in the personal information above and that I am filling out this registration form in agreement with any other parent or legal guardian of that child.

* I, the parent/legal guardian of the child whose name appears in the personal information above, have read and understood the four steps to infant circumcision.

* I, the parent/legal guardian of the child whose name appears in the personal information above, understand that I will have to pull down on the inflamed skin that could cover the glans again and this 48 hours after the circumcision, even if it is sensitive for my child. Otherwise, I understand that complications could ensue and that the aesthetic appearance will be sub-optimal.

* I, the parent/legal guardian of the child whose name appears in the personal information above, ask Dr. Jean-Philippe Bercier to perform a circumcision on my child. I also understand that I may need to go to Dr. Bercier’s office or the hospital for evaluation or treatment should there be a rather rare complication. By consenting to my child’s circumcision and accepting the risks described above, I discharge Dr. Bercier of any responsibility in terms of lost working hours, unearned salary or any other medical expense related to treating a complication.

* I know I will have to provide a valid credit card number in order to obtain a date for my vasectomy. I also understand that a 7 day notice is required to cancel, or postpone, my appointment date; otherwise a $150 fee will be charged to my card. If I cancel or postpone within 24 hours, a $250 fee will be charged.

* I, the parent/legal guardian of the child whose name appears in the personal information above, know I will have to provide a valid credit card number to obtain a date for the circumcision procedure. I also understand that a 7 day notice is required to cancel or postpone my appointment date; otherwise a $400 fee will be charged to my card.

* I know I will have to provide a valid credit card number in order to obtain a date for my vasectomy. I also understand that a 10 open business day notice is required to cancel, or postpone, my appointment date; otherwise a $250 fee will be charged to my card.

* I, the parent/legal guardian of the child whose name appears in the personal information above, know I will have to provide a valid credit card number to obtain a date for the circumcision procedure. I also understand that a period of 10 open business days is required to cancel or postpone my appointment date; otherwise a $400 fee will be charged to my card.

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MONTREAL

REMD Solutions

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HAWKESBURY - VASECTOMY

HAWKESBURY – CIRCUMCISION

HAWKESBURY - VASECTOMY REVERSAL

Ruby Medical Center

REMD Solutions Inc.

Ottawa Clinic