The information provided will be treated in the STRICTEST CONFIDENCE

    If you prefer to be anonymous, please leave blank

    To help us to provide the best vasectomy service possible, feedback from you is essential.

    Now that you have had one semen sample clear of sperm, I would be grateful if you would spend a few minutes completing the following questionnaire:

    Prior to your procedure
    Please rate the following in the range of 1 (poor) to 5 (excellent)

    During your procedure:
    Please tick your answers where appropriate

    After your procedure
    Please rate any problems you had arising after the vasectomy using a scale of 1 (minimal) to 5 (severe)

    Any further comments?

    Thank you for taking the time to complete this questionnaire. Your feedback will be treated confidentially and will help improve services to our patients.