¡Nos alegra que esté pensando en dar el siguiente paso!
A continuación se muestra un formulario breve para recopilar su información básica. Para completar esto, necesitará su información de contacto, su información médica (como el nombre de los medicamentos y las alergias) y una copia de ambos lados de su tarjeta de seguro médico (si tiene un seguro que planea usar).
Recopilamos esta información para poder comunicarnos con usted con la información más precisa posible.
¡Gracias!
Request Appt
Would you like to schedule a consultation prior to the vasectomy, or just schedule the vasectomy?
Vasectomy Scheduling--you have the option of waiting until after the consultation to schedule your vasectomy, or scheduling now. If you schedule now, you'll put down a $120 deposit. This is refundable until 2 weeks prior to the appointment.
Language preference
Address
City
State/Province
Zip/Postal

Medications

for example, lisinopril, 20 mg
for example, one tablet twice daily

Medication Allergies

You have the option of having a medication (one tablet of lorazepam is generally used) prescribed to help you relax prior to the procedure. This is not generally recommended; it’s only recommended for guys who are VERY nervous. Would you like to use this? *

Preferred pharmacy details

We'll need the exact name and address (street number, street name, city, and zip code). We can't use "King Soopers at 30th and Arapahoe". You'll need to give us King Soopers Pharmacy, 1650 30th St, Boulder, CO 80301.
Address
Address
City
State/Province
Zip/Postal
Have you fainted with medical procedures?
Do you have a history of genital or urinary conditions? *
Please mark any you've had, explain something else OR "No genital or urinary conditions for me"
Are you in a long term relationship? *
Please check here if you are a current Trailhead Clinics member
You can join the video consultation from a phone or computer. What device will you be using for that session, and how do you prefer to connect? *
What location would you like to use for your vasectomy? *

VASECTOMY SCHEDULING

After choosing a location, you'll see available dates and times. If you'd like to see possible dates at other locations, you can change the location above.

Consent for Treatment, Privacy Policy and Use of Electronic Communication

Acknowledgement of Consent for Treatment and Privacy Policy *

Deposit to hold vasectomy appointment

Credit Card

Consult (Hidden)

Procedure (Hidden)