His Choice Raleigh Sedation Vasectomy Scheduling Questionnaire Logo
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  • His Choice Raleigh Sedation Vasectomy Scheduling Questionnaire

    Sedation vasectomy procedures are only offered at the His Choice Raleigh location.

  • Scheduling Sedation Vasectomy

    If you are ready to schedule sedation vasectomy then:

    • Your Body Mass Index (BMI) must be below 40
    • You will be required to pay in full for surgery within 24 hours of completion of phone scheduling with the nurse

    Do not submit this form if your BMI is above 40 or you are unable to pay in full within 24 hours of phone scheduling with the nurse.

    Please call our office with questions.

    Steps You Will Need to Complete

    If you are ready to schedule surgery then these are the steps you will need to take:

    1. Complete this form and pay the scheduling fee when finished
    2. A nurse will call you within 48 hours to complete scheduling over the phone
    3. After the phone interview the nurse will email you surgery documents
    4. Electronically return signed documents
    5. Send full payment within 24 hours

  • THIS IS NOT THE CORRECT FORM!

    If you are not trying to schedule a sedation vasectomy procedure do not fill out this form.

    Please call the office (919) 977-5060 and speak with a staff person. 

  • If you are financing all or part of your surgery then you should have arranged financing from one of the finance companies listed on our website prior to submitting this form. 

  • Card Owner

    Please enter name and email address of the card owner without errors.

  • If the card owner is not the patient, then the card owner will need to be physically present with the patient at the time of surgery consultation visit.

    The card owner will be required to sign a credit card authorization in the office on the day of the consultation appointment.


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  • Financial Guarantor

    Please enter name and email address of the person who is the financial guarantor for surgery financing.

  • If another person is using their name and credit score to pay for your surgery using their credit card, CareCredit card, FSA/HSA/Advance Care Card or financing your surgery then they are your financial guarantor :

    The scheduling nurse will need their full legal name and email address because that person will need to sign your financial documents.

    Your financial guarantor will need to be present during your consultation appointment to co-sign your financial contracts in person.


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  • Patient Information

    Please enter information as accurately as possible. Please enter your name, date of birth, and email address without errors.

  • Please use your legal name as it appears on your driver’s license or government issued identification.

  •  / /

  • Please use an email you check often.


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  • We recommend you avoid strenuous exertion and sexual activity for two (2) days after sedation vasctomy.

  • Desired Surgery Date

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  • You cannot consider your procedure date confirmed until: 

    • Your signed documents have been returned
    • Your full payment has been received by our office

    DO NOT MAKE TRAVEL OR HOTEL ARRANGEMENTS UNTIL ALL OF THE ABOVE ITEMS HAVE BEEN COMPLETED

  • Body Mass Index Calculator

    We require your BMI be less than 40 to have surgery at our center

  • If your BMI is over 40 you will not be able to have sedation vasectomy until your BMI is less than 40

    Do not submit this form.


    Call and speak with a scheduling nurse for advice.

    All patients will have their height and weight measured and official BMI calculated during their consultation apointment.

    Often patients will enter incorrect information at the time of scheduling because:

    • They are not certain about their height or weight
    • They are over the maximal BMI limit and hope to lose weight before their surgery

    If you are over the BMI limit at the time of your consultation appointment your surgery will be cancelled and you will lose 100% of your surgery fee.

    Exceptions are never made to the BMI policy.

  • High Risk Medical Conditions

    If you do not know what the conditions are then you probably do not have them!

  • DO NOT SUBMIT THIS FORM if you have any of the high risk medical conditions in this section. 

    Call and speak with a nurse.

  • Conditions which require a consultation appointment before scheduling a sedation vasectomy procedure

  • If you have any of the above conditions you will need to schedule a consultation before you can have a sedation vasectomy procedure.

    Please call and speak to a nurse if you have questions.

  • Prescription Blood Thinners

    If you are currently taking a prescription blood thinner, then you should complete and submit this scheduling form.

    The Scheduling Nurse will provide more information and will send you a referral letter to take to a hematologist for their recommendations. 

    The hematologist will need to provide specific recommendations about management of your blood thinner before, during, and after sedation vasectomy. Their recommendations will need to be sent to our office before your procedure.

    If they recommend you be on a blood thinner during your vasectomy procedure then you will not be a candidate for vasectomy at our center.

  • Medical History

  • You should stop herbal remedies or aspirin at least three (3) weeks before surgery. These medications can cause bleeding.

    You can use acetamiophen (Tylenol) or ibuprofen in limited amounts if needed. These medications do not increase the risk of bleeding.

  • You will need to bring any inhalers or breathing medications with you on the day of your consult and surgery.

  • You will need to bring your CPAP machine with you on the day of your consult and surgery.

  • You will need to bring your blood pressure medications with you to your consult and surgery.

  • You will need to bring any diabetic medications with you on the day of your consult and surgery.

  • You will need to bring your thyroid medication with you on the day of your consult.

  • Semen Sample Testing After Sedation Vasectomy

  • A confirmatory semen sample to confirm the success of the procedure is recommended three (3) months after your sedation vasectomy procedure. 

    We specifically recommend you abstain from sexual activity of any kind for 48 hours after your procedure. After 48 hours, you may resume sexual activity if you feel comfortable. After sedation vasectomy, you will need to:

    1. Continuing using your current method of birth control

    2. Have a minimum of 20 ejaculations 

    3. Wait at least three (3) months.

    Pregnancy is possible until we evaluate your semen sample and document clearance of sperm.

    Options for semen sample testing after vasectomy

    1. You have four (4) options for semen sample testing
    2. Bring us a fresh semen sample
    3. Mail us a semen sample
    4. Take your sample to an lab near your home
    5. Use a home test semen analysis like SpermCheck for after vasectomy

    Our office will perform a semen sample test for you for you at no charge if you bring us a fresh sample or mail us a sample.

    If you would like your semen tested at an outside lab near your home, you will need to let us know at the time of your procedure and we will provide you with a lab order. You will be responsible for the cost of any testing performed at an outside lab.

    You can order a home test kit like SpermCheck after vasectomy from Amazon. The kit will be delivered to your home and the test can be performed in the privacy of your own home. You are responsible for the cost of the test kit.

  • Accompanying Adult

    An Accompanying Adult will need to be with you before, during, and after your sedation vasectomy procedure. This person must be above the age of 18.

    If you have another person paying for your surgery (financial guarantor) with a credit card or financing then this person must be with you during your consultation to sign our paperwork.

    Your Accompanying Adult will need to:

    • Be present during your consultation appointment
    • Remain in our facility the entire time you are having surgery
    • Help you to return home

    If you do not have a Accompanying Adult with you on the day of your sedation vasectomy procedure then your surgery will be cancelled and you will forfeit your entire surgery fee.

  • Sedation Vasectomy Surgery Confirmation

  • You cannot consider your sedation vasectomy date confirmed until:

    1. Your phone scheduling interview with our nurse is completed.
    2. All documents have been signed and retured.
    3. Your surgery fee has been paid in full.

    Once your scheduling interview is completed, all signed documents have been returned, and your surgery fee has been paid then your surgery date wil be confirmed and, if required, it will be safe to make hotel and travel arrangements.

    If we uncover any high-risk medical conditions during the phone scheduling interview, we may determine you are not a safe surgical candidate for outpatient surgery under general anesthesia. 

    The scheduling fee is not refundable under any circumstance.

    If you have something in your history you are concerned about you should call and speak with a nurse before submitting this form.

  • Sedation Vasectomy Surgery Policies

    By checking each box below you are acknowledging you understand each policy.
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    Surgery Scheduling Fee Product Image
    Surgery Scheduling FeeNon Refundable
    $180.54
      
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    $0.00

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