Patient Registration for World Vasectomy Day (WVD)

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    TERMS & CONDITIONS

    In registering to participate in WVD, I fully acknowledge all of the following statements: In submitting this form, my details will be forwarded to the appropriate medical officers assigned by the organisers of WVD (Smith&Nasht) to assess my registration for a vasectomy on WVD. The risks involved in having a vasectomy are as described in the required consent form and that the organisers of WVD shall be held blameless. My vasectomy procedure will be video recorded, live streamed on the internet and potentially repurposed by the organisers of WVD. I understand that I may be identifiable from the video recording and that it may appear in a subsequent feature length version of the documentary film “THE VASECTOMIST”. I will need to supply a signed consent form in hard copy to be made available to the organisers of WVD in order to have my vasectomy performed on WVD. Submitting this form does not automatically guarantee my vasectomy will be performed on WVD. My medical record will be held in a secure electronic and/or hard copy form and the organisers of WVD may use electronic transmissions in the management of my medical record and care. I understand that the record will only be accessed by approved users during the course of their work. I may be contacted by phone or email. The organisers of WVD undertakes to not use any information that would identify my health record individually without my consent except where legally required or requested with my consent including transfer or copying medical records. WVD organisation conforms to the requirements of Privacy Legislation. 'The organisers' refers to the organisers of WVD, Smith&Nasht.
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