No-needle, no-scalpel vasectomy
Dr Stein technique

BOOKING AN APPOINTMENT

OTTAWA/GATINEAU

Ottawa Medical Group

For the Orléans clinic the procedure is covered by OHIP and RAMQ.

MONTREAL

REMD Solutions Inc.

For the Montreal clinic fees of $ 495 (taxes included) are applicable, which include consultation fees, procedure and equipment. Most insurance cover the procedure and different payment methods are available (cash, credit, debit).

HAWKESBURY

Ruby Medical Center

For the Hawkesbury clinic the procedure is covered by OHIP and RAMQ

CONTACT ONE OF OUR CLINICS

CHOOSE A SERVICE

PERSONAL INFORMATION

Personal Details

Preferred Phone

OCCUPATION

Level of exertion at work

PHYSICIAN INFORMATION

If the doctor who referred you is not your family doctor, please write the name of your usual family physician.

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

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?

REFERENCE

How did you find us?

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 know I will have to provide a valid credit card number to Dr. Bercier's team in order to obtain a date for my vasectomy. I also understand that a delay of 7 business days is required to cancel, or postpone, my appointment date; otherwise a $100 fee will be charged to my card. Otherwise, the credit card information will be destroyed.

* 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, know I will have to provide a valid credit card number to Dr. Bercier’s team to obtain a date for the circumcision procedure. I also understand that a period of seven business days is required to cancel or postpone my appointment date; otherwise a $100 fee will be charged to my card or the credit card information will be destroyed.

* 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.