Self Referral Form for an NHS funded vasectomy (free for patients)

Please complete the form below to the best of your ability. Once you have submitted the form the process for a self referral is started. If we find out you are not elegible we will signpoint you either to our private service or, if you are elegible, to a GP referral or both depending on your preference. Please ensure you are fully aware of the Terms and Conditions before completing the form.