Refer a patient for a vasectomy

If you are a healthcare professional and wish to refer a patient please fill out the form

Your Full Name(Required)

First Last

Your Email(Required)

Your Phone

Te Whatu Ora Health New Zealand District (if relevant)(Required)

I am a(Required)

Patient's Name(Required)

First Last

Patient's Email(Required)

Patient's Phone(Required)

Patient's Date of Birth(Required)

Patient's Address

Street Address Address Line 2 City ZIP / Postal Code

Patient's NHI Number (if known)

Name of Patient's GP Practice

Name of Patient's GP

Reason for referral(Required)

Snip Vasectomy Clinic
PO Box 5615
Terrace End
Palmerston North 4441