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Gentle Procedures Toronto

No-Scalpel Vasectomy
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No-Scalpel Vasectomy
Circumcision
Penile Frenulectomy
Contact
About
Resources

Vasectomy Registration

Thank you for booking your vasectomy with Gentle Procedures Clinic

Before you arrive to your appointment, you are required to complete our registration and intake forms.

All patients must ensure their OHIP cards are valid at the time of the appointment. If you need to update your OHIP card, you may do so here. It only takes 5 minutes!

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This field is for validation purposes and should be left unchanged.
Patient Information
Name*
First Last
Date of birth*
MM slash DD slash YYYY
Preferred Phone Number*
Email*
Occupation
OHIP Number*
OHIP Version Code (the letters after the number)*
Type N/A if none
Medications
Please list any medications you are taking including name and dosage: (including Aspirin, Advil, other anti-inflammatories)*
Type "N/A" if none
Surgical History
Please check if you have had any of the following:*
- Scrotal or testicular surgery
- Hernia
- Previous vasectomy
- Vasectomy reversal
- NONE OF THE ABOVE
Health History
Please check all of the following that apply to you:*
- Ache, pressure or pain in the testicles or groin
- Bleeding problems
- Hepatitis A, B, C
- HIV/AIDS
- Genital warts
- Scrotal or testicular injury or trauma
- Undescended testies
- History of fainting due to medical procedure or injection
- NONE OF THE ABOVE
Untitled*
- I confirm that the information I have provided above is true and accurate. I have been given the opportunity to clarify any questions before providing answers to these questions

Vasectomy Agreement
Vasectomy Agreement*
- I hereby authorize Dr. Roland Sing to perform No-Scalpel Vasectomy on myself and understand the importance of following post-operative care instructions provided to me by Gentle Procedures Clinic.
- I confirm that I have followed all of the pre-operative instructions that were provided to me during my appointment booking call, and included in my appointment confirmation email.
- I understand that this operation should be considered a permanent contraceptive, however I also understand that that there is a possibility of failure.
- I understand that it will be necessary for me to complete a semen analysis test 3 months after my vasectomy procedure and should not consider myself to be sterile until I have received my negative post-vasectomy semen analysis results from Dr. Sing’s office and have been advised to continue to other forms of contraceptive until my sterility have been confirmed.
- I understand that, as any other operation/medical procedure there are known and unknown risks and complications associated with no-scalpel vasectomy including but not limited to scrotal hematoma, infection, epididymitis, sperm granuloma, post vasectomy pain syndrome, late failure, and pain that may require further medical treatment. Any questions I have regarding potential risks and complications have been answered and explained to me to my satisfaction.
- I understand that the clinic requires at least 5 business days' notice to cancel/reschedule my appointment, otherwise I may be required to provide an additional deposit in order to reschedule. It has also been explained to me that arriving to my appointment with an expired health card will result in a forfeited deposit and returned to me only when I provide the clinic with my updated health card information.
- I understand that my appointment may be cancelled by the clinic, resulting in a forfeited deposit should any of the following reasons apply: • Failure to confirm appointment (we email confirmation messages 6 days before each scheduled appointment). • Arriving late to appointment. • Arriving to appointment unprepared, and according to the pre-operative instructions that were provided at the time of booking and included in our confirmation email.
- The anticipated results, nature, and risks associated with vasectomy have been explained to me to my satisfaction.
- I request this procedure voluntarily, of my own free choice.
- I have carefully read or have had read to me the above, and I understand and accept the terms and conditions.
- I confirm that I am fully aware of and understand the contents of this agreement.

Electronic Communication Consent
Electronic Communication Consent*
- Dr. Roland Sing and his staff at Gentle Procedures Clinic Toronto, regularly communicate with and provide patients with their services through electronic communication and internet technology, such as email, text messaging (including instant messaging), and/or electronic medical records (EMR) portal. I hereby acknowledge and agree to the following:
  
  1. Risks of using electronic communication
  The physician will use reasonable means to protect the security and confidentiality of information sent and received using the Services outlined in this consent. However, because of the risks outlined below, the physician cannot guarantee the security and confidentiality of electronic communications:
  • Use of electronic communications to discuss sensitive information can increase the risk of such information being disclosed to third parties.
  • Despite reasonable efforts to protect the privacy and security of electronic communication, it is not possible to completely secure the information. Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.
  • Electronic communications can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, and security settings.
  • Electronic communications are subject to disruptions beyond the control of the physician that may prevent the physician from being able to provide services.
  • Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the physician or the patient.
  • Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.
  • Electronic communications may be required to be disclosed in accordance with law, a court order or other legal process. The exceptions to confidentiality include, but are not limited to, addressing imminent risk of serious harm to self or others; providing information in response to a subpoena or court order; providing information required by legislation (e.g. SGI or WCB), and as otherwise permitted under The Local Authority Freedom of Information and Protection of Privacy Act or The Health Information Protection Act.
  • Video conferencing using no cost, publicly available services may be more open to interception than other forms of videoconferencing.
  • There may be limitations in the services that can be provided through electronic communications, dependent on the means of electronic communications being utilized.
  • Email, text messages, and instant messages can more easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients.
  • Email, text messages, and instant messages can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has been sent.
  
  2. Conditions of Using Electronic Communications
  • While the physician will endeavor to review electronic communications in a timely manner, the physician cannot provide a timeline as to when communications will be reviewed and responded to.
  • If your electronic communication requires or invites a response from the physician and you have not received a response within a reasonable time period, it is your responsibility to follow up to determine whether the intended recipient received the electronic communication and when the recipient will respond.
  • Electronic communication is not an appropriate substitute for in-person or over-the-telephone communication or clinical examinations, where appropriate, or for attending the Emergency Department when needed. You are responsible for following up on the physician’s electronic communication and for scheduling appointments where warranted.
  • Electronic communications concerning diagnosis or treatment may be printed or transcribed in full and made part of your medical record. Other individuals authorized to access the medical record, such as staff and billing personnel, may have access to those communications.
  • The physician may forward electronic communications to staff and those involved in the delivery and administration of your care. The physician might use one or more of the Services to communicate with those involved in your care. The physician will not forward electronic communications to third parties, including family members, without your prior written consent, except as authorized or required by law.
  • You agree to inform the physician of any types of information you do not want sent via the Services. You can add to or modify the above list at any time by notifying the physician in writing.
  • Some Services might not be used for therapeutic purposes or to communicate clinical information. Where applicable, the use of these Services will be limited to education, information, and administrative purposes. The physician is not responsible for information loss due to technical failures associated with your software or internet service provider.
  
  3. Instructions for communication using the Services
  • Reasonably limit or avoid using an employer’s or other third party’s computer.
  • Inform the physician of any changes in the patient’s email address, mobile phone number, or other account information necessary to communicate via the Services. If the Services include email, instant messaging and/or text messaging, the following applies:
  
  • Include in the message’s subject line an appropriate description of the nature of the communication (e.g. “prescription renewal”), as well as your full name and date of birth in the body of the message.
  • Review all electronic communications to ensure they are clear and that all relevant information is provided before sending to the physician.
  • Ensure the physician is aware when you receive an electronic communication from the physician, such as by a reply message or allowing “read receipts” to be sent.
  • Take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.
  • Withdraw consent only by email or written communication to the physician.
  • If you require immediate assistance, or if your condition appears serious or rapidly worsens, you should not rely on the Services. Rather, you should call the Physician’s office or take other measures as appropriate, such as going to the nearest Emergency Department or urgent care clinic.
  
  4. Acknowledgement and Agreement
  • I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected electronic communications as described above. I understand and accept the risks outlined above to this consent form, associated with the use of the electronic communications with the physician and the physician’s staff. I consent to the conditions and will follow the instructions outlined above, as well as any other conditions that the physician may impose regarding electronic communications with patients. I acknowledge and agree to communicate with the physician or the physician’s staff using these electronic communications with a full understanding of the risks in doing so.
  • I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that communications with the physician or the physician’s staff using the Services may not be encrypted. Despite this, I agree to communicate with the physician or the physician’s staff using these Services with a full understanding of the risk. I acknowledge that either I or the physician may, at any time, withdraw the option of communicating electronically through the Services upon providing written notice.
  • I confirm that any questions that I had regarding the provision of healthcare services through electronic communications have been answered by the physician or delegate.
  • I consent to having physician Dr. Roland Sing and his staff, through the Gentle Procedures Clinic Toronto, communicate with and/or provide me with their services through electronic communication and internet technology, such as email, text messaging (including instant messaging), and/or electronic medical records (EMR) portal.
- I confirm that I understand and consent to the use of Electronic Communication.
Patient Signature*
Date*
DD slash MM slash YYYY
Witness Signature*
Date*
DD slash MM slash YYYY

Gentle Procedures Toronto

Gentle Procedures Toronto

77 Queensway West, Suite 310
Mississauga, Ontario, L5B 1B7

Call us : 416-551-7070 | CONTACT US

Fax : 416-551-7171

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