Please review the following risks of vasectomy. They are explained further in the counseling video HERE, which you should watch before proceeding.  If you have questions about any of these risks, contact us before you sign this. 

• I will later decide I want a pregnancy, but I will be unable to reverse the procedure. The reversal surgery is expensive, and it is sometimes not successful. 
• That surgery cannot be completed. The shape of the scrotum for some men makes no-scalpel vasectomy difficult. There is a risk that one or both of your tubes cannot be located and divided. The risk of this is higher when you have not had an exam prior to the procedure.  About 1 in 200 men will have this problem. 
• Pain. It is normal to have pain for the first 2-3 days, but some men have pain that lasts many months. This is referred to as “Chronic Post-vasectomy Pain Syndrome.” About 1 in 250 men will have this. 
• Swelling. Some swelling is normal, but some men will have unusual swelling that only subsides with time. It may be painful.  About 1 in 50 men will have this problem.
• Allergic reaction to the numbing medication or other product used during the procedure.
• Infection in the tissues of the scrotum or spreading elsewhere.
• Failure. The surgery may not succeed in separating both tubes.  Also, the tubes may develop a connection later in life.  The risk of this is small, about 1 in 1000 men. 
• The need to alter the planned procedure.  If this happens, I give permission to my doctor to alter the procedure as necessary, or to administer additional anesthetics or other medication if I should need them, for the completion of my procedure.
• That my insurance may not agree to pay any part of the procedure and I will be responsible for the full amount.