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Dr Simon Wilson
Direct Access Vasectomy
227 Bell Street
Preston VIC 3072
Phone: 9416 9888  Fax: 9416 8020

RE:  	<PtFullName>
              DOB: <PtDoB>
	<PtStreet>
	<PtCity> <PtPostcode>
	Ph: <PtPhoneH> Mobile: <PtPhoneMob>
	Medicare Card: <PtMCNo>

Thank you for seeing <PtPrefName> <PtSurname> , aged <PtAge>, for consideration of vasectomy. 

He has No/1, 2, 3, 4, 5, 6 children and desires permanent sterilsation to avoid future pregnancies. He understands that he is not sterile immediately after vasectomy but needs to continue contraception with condoms/OCP/IUD/Implanon until a semen test at three months to ensure sterility. 

There is   No/Yes history of groin or testicular surgery/trauma. 

History of fainting No/Yes

Occupation is:

		     
<HisHer> current medications are:<CurrentRx>
Allergies:<Reactions>
Past Medical History:<PMHAll>

Kind Regards

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