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  • Medical Intake Form | Dads Again

    "*" indicates required fields

    Required Medical History Intake

    Takes about two minutes to complete! Please, put "Not Applicable" for any required fields that do not apply to you.
    Name:*
    Address*
    MM slash DD slash YYYY
    Please enter a number from .5 to 50.
    Do you and your wife / SO share children?*

    Lifestyle

    Please, provide details such as what you smoke, how often, etc.
    Please, provide details such as what you drink, how often, etc.
    Please, provide details such as when you started, the dosages, how often, etc.
    Please, provide details such as what you are taking, the dosages, how often, etc.

    Medical History

    Please, provide details such as what you are taking, the dosages, how often, etc.
    (Was it a scrotal incision? Were there 2 incisions made? Were there any complications with your vasectomy?)

    Communication with the office of International Center for Vasectomy Reversals:

    Do you give us permission to leave you voicemails?*
    Do you give us permission to communicate with you via email?*