YOU MUST DO THE FOLLOWING BEFORE YOUR ONLINE REGISTRATION CAN BE SUBMITTED AND ACCEPTED BY OUR OFFICE:

  • You must review all the educational materials on this site.

  • You must obtain a referral from a family physician to see Dr. Pollock for the surgery (which you are required to do anyway before our office will see you)

  • You will ensure that you have been off any Aspirin or other anti-inflammatory medication for a minimum of 10 days before your booked consult/surgery appointment.
    If you book you surgery and attend the clinic at the arranged day and time but you have done something that you were clearly instructed not to do i.e take ASPIRIN, IBUPROFEN, etc, or any anti-coagulant such as WARFARIN (COUMADIN) ,etc within the previous week, thereby requiring surgery to be cancelled, you understand that you will be required to pay a cancellation fee of $250.00.
    (IF YOU ARE NOT SURE, PLEASE DOUBLE CHECK THIS WITH US BY CALLING 604-717-6210 BEFORE TAKING ANY MEDICATION).
    (Please note TYLENOL is not an anti-inflammatory and is okay to be taking)

  • You will have reviewed the sperm banking information on this site.

  • You will have downloaded the pre-op & post-op information manual:
    English version
    Chinese version
    Korean version
     to print out and review.

  • If you have satisfied all of these, you must ensure that you have properly filled out the following medical history questionnaire and submit that directly to our office.

Dr. Pollock will then review each patient's history and make sure that all questions are answered by telephone before the day of the patient's consult/ surgery. When you arrive at the office for your first visit, it will include a brief discussion and examination followed by what is usually a 7 minute virtually bloodless painless procedure. After your surgery and few minutes of observation, you will be able to drive yourself home.

Should you decide to go through the optional online registration process ( a non-insured service) which saves you one visit to our office, a charge of $50.00 will be applied to your credit card which covers non insured administrative services including a telephone discussion with Dr. Pollock.

On rare occasion we may not receive a submitted form. We want to be clear, you should contact the office at 604-717-6210 within 2 business days if you have not received your phone call from Dr. Pollock.

Patient Identification Form:

Please print your name as it appears on you B.C health insurance care card

Current Date:
Email:
First Name:
Last Name:
Care Card Number:
   (0000 000 000)
(You must bring your care card on the day of your consult/surgery)
Birth Date:
Age:
Address:
City:
Postal Code: 000-000
Home Phone Number:  000-000-0000
Work Phone Number:  000-000-0000
Occupation:

Family Doctor:
Family Doctor's Phone Number:  000-000-0000
Family Doctor's City:
Referring Doctor:
Referring Doctor's Phone Number:  000-000-0000
Referring Doctor's City:
Name of relative in case of emergency:
Relatives Phone Number:  000-000-0000

How did you find out about Dr.Pollock?

Currently in relationship?
Type of relationship:
Length of current relationship (years):
Your partner's age:
Number of children with current partner:
Number of children with previous partner:
Number of children your partner brought into the relationship:
Age of youngest child:
(state exactly how many years and months)

Current type of contraception used:
Other type of contraception, please specify:
Partner currently pregnant:
If yes, what is the expected date of delivery?
Are you aware of the syndrome "Sudden Infant Death Syndrome"?        
(mentioned in case you have a young child)

Any current sexual problems?
If yes, please specify:
Any medical problems?
If yes, please specify:
Medications?
(You need to record the correct spelling of your medication with the accurate dosage in milligrams and the frequency taken)
If yes, please specify:
Allergies?
If yes, please specify:
Bleeding Problems?
If yes, please specify:

Have you had any of the following?
Hepatitis A, B or C:
If yes, please specify:
Homosexual Contact:
Blood transfusion:
HIV or AIDS:
History of IV Drug abuse:
Any previous injury or surgery to scrotum, testicles or repair of hernia?
If yes, please specify:

Waist size; from 24 to 54:
I have read and understand the sperm banking information on this website:
I have printed the forms and will be storing sperm.
I decline sperm bank storage.

This is my preferred contact number:  000-000-0000
Please be advised that our office will contact you within a few days of receiving your submitted form.
For the most prompt access to arranging and confirming your vasectomy, you are welcome to call our office (604-717-6210) as early as 3 hours after submitting your internet registration. We will try our best to connect you immediately with Dr. Pollock who will speak with you directly, after which your booking will be confirmed.

 

Should you decide to go through the optional online registration process ( a non-insured service) which saves you one visit to our office, a charge of $50.00 will be applied to your credit card which covers (non-insured) administrative services including a telephone discussion with Dr. Pollock.

Yes, I understand    

 

If this is being submitted by the female partner of the patient, Please DO NOT submit this until the patient himself has read the entire website.

I understand that since Dr. Pollock will not be examining me till the day of my surgery that there is about a 1% chance that he will find something at the time of the examination that will not allow us to proceed with the surgery.

Please note that if you are not contacted by Pollock Clinics within 2-3 business days, please call our office at: 604-717-6200 to confirm your registration submission has been received.

I understand that I can book a surgery and cancel it at anytime 2 working days or more before my surgery without any penalty. However I will be required to pay a cancellation fee of $250.00 if:
  1. I book surgery and do not show up for my surgery.
  2. If I book a no-scalpel vasectomy and cancel it with less than 2 working days notice to the clinic (thereby not allowing the staff to book another patient in my place).
  3. I book my surgery and attend the clinic at the arranged day and time but I have done something that I was clearly instructed not to do i.e take aspirin within the previous week, thereby requiring my surgery to be cancelled.
Yes, I understand