ONLINE NSV REGISTRATION
Please answer each of the questions on this page. It is important that we have accurate knowledge of your background, medical history, reproductive history, and future
plans and expectations in order to best serve you, answer all questions at least a day before your appointment day.Your privacy and confidentiality is guaranteed!
Email *
Demographic Info
N/B: The form should be submitted at least a day before the procedure
What is the reason for choosing Vasectomy as your preferred family planning method. *
Required
Your Name (required) *
Town (required) *
Country (required) *
Mobile No (required) *
Level of education
Clear selection
Employer
Occupation
Level of Exertion at Work
1. Any allergy to drugs? *
2. Are you on any medicine? *
3. Have you had any of these operations? *
4. Have you had any of these problems? *
Required
1. What is your Age? *
2. a) Marital Status *
Required
b) What is your Partners Age? *
3. a) If Married: Is Wife Pregnant? *
b) How many marriages have you had *
c) Total number of children *
d) how many living male children *
e) How many living female children *
e) Age of youngest child *
f) Were all your children planned? *
6. Contraceptive Methods used in the last 1 Year *
Required
7. Who Referred You Here? *
Required
A copy of your responses will be emailed to the address you provided.
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