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Men-4-Men vasectomy fund (Click here to see this form in pdf format, which you can download and print out.) Men-4-Men Doctor Letter Dear Doctor, The Men4Men Fund has been given your name by a potential patient who is planning to have a vasectomy. This letter is to let you know about the Men for Men Fund and how it can help you get paid. Quaker Earthcare Witness (www.quakerearthcare.org) is a religious group concerned about the environment. Because we feel that our rapidly growing population is a major factor in causing the environmental problems that we all face, we have established the Men-4-Men Fund. We wish to help prevent unplanned pregnancies by making vasectomies available to men who would otherwise have difficulty affording them. At present, we are limiting the funding to Quakers. We are a small organization with limited funding and can only pay part of the usual cost of a vasectomy. The stipend is $350. We hope that you will take this as payment in full for your services. If not, please discount your fee to make the vasectomy affordable by your patient. The final financial arrangements are between you and him. We have provided your patient with some preliminary information about vasectomy, including its permanence, the risks of failure, infection and hematoma, and that it is not immediately effective. This should not be construed as informed consent. We stress that you will be providing your patient with more information. You will need to make arrangements with him about testing for sperm. The timing of this testing is up to you. We cannot be responsible for any extra payment for this testing. Our payment will be directly to you. We suggest that after your initial consultation, your patient should submit the "Information and Application Form" to Quaker Earthcare Witness. We will consider this quickly. If approved, a check for $350 will be mailed to you. We would appreciate your holding the check until the vasectomy has been performed. Thank you for your willingness to cooperate with the Men-4-Men program. Quaker Earthcare Witness Men-4-Men Information and Application Form Criteria: Stipends are based on need, and are available to men who attend or belong to a Friends Meeting or Friends Church. There is no requirement of family size, but the client must be at least 21 years of age. Men who apply are responsible for finding a physician who will perform the surgery. The doctor may accept the $350 stipend for the whole cost of his services, or the man may need to pay an additional amount. QEW does not assume legal responsibility for the end results of any decision made by the person applying for this stipend. Information about vasectomy: (This information was prepared by R. Grossman, MD.) Vasectomy is a minor surgical procedure performed to make the man permanently sterile, so he cannot father children. It involves blocking the vas deferens that carry sperm from the testicles. It is usually done with local anesthesia in a doctor's office. It takes an hour or less to perform, and usually there is only mild discomfort. Most men will have some pain afterwards, and will probably need to avoid heavy work for a few days. The doctor who performs the surgery can give you more information on what to expect. You can also find more information at: www.vasectomy.md. In the past there has been a concern that men who had a vasectomy are more likely to develop prostate cancer when they get older. Now this is not thought to be the case. Perhaps the reason this wrong association was made is a quirk of medical care. Men who have vasectomies are likely to be middle class. They are more likely to go to doctors on a regular basis, and to have prostate cancer discovered. More accurate studies have shown that there is no association between this very safe procedure and cancer. Sperm make up only a tiny part of the ejaculate, so neither the man nor his partner will be aware of the change during sex. Most men find that their sex lives do not change, except to take away the fear of an unplanned pregnancy. Because sperm are stored for a while, it may take some time before a man is sterile after this surgery. Your doctor can tell you how long; sometimes it is a period of time (up to 3 months) or a number of ejaculations. Most doctors require a test to be sure that all of the sperm are gone from the ejaculate. Like any surgical procedure, there are some risks. They include a bruise or swelling of the scrotum, infection, and failure. Most failures occur shortly after the surgery. These failures occur because the man didn't wait long enough for the sperm to disappear, or (in rare cases) because the surgery failed. Some failures occur a long time after the procedure because the little tubes can grow back together—but this is very rare. It is best to choose a doctor with a lot of experience with vasectomies since the complication rate is apt to be lower. Your doctor is responsible for explaining the risks to you, and you should read and sign an informed consent before the actual surgery. The Men for Men Fund and Quaker Earthcare Witness do not have any responsibility if the surgery has a complication. We hope that the surgery goes well, and that you are pleased with the result. Occasionally men change their minds and wish to regain their fertility. We cannot help pay for surgery to undo the vasectomy. We hope that you consider carefully before deciding to permanently finish your ability to father children, and that you will discuss your decision with your partner. I have read and understand the material on this page. Initials: _________
About Men-4-Men: Quaker Earthcare Witness (www.quakerearthcare.org) is a Quaker organization, the members of which are very concerned that our planet's resources have been stretched to the breaking point. As Quakers, we feel that simplicity is one key to solving the environmental problems that surround us. We are aware that a large part of the problem is the numbers of humans on Earth. Men for Men was started after a QEW member suggested that a fund to help pay for vasectomies would be one way to decrease the number of unplanned pregnancies. The stipend of $350 will be paid directly to the physician who performs the surgery, probably after the initial visit and before the surgery. It is up to you to negotiate the total price that is paid for the surgery; any amount in excess of the $350 stipend is your responsibility. Please see the letter addressed to the physician. We are starting by offering a stipend to men who attend or belong to a Friends Meeting or Friends Church. If this pilot program is successful, we hope to expand it in the future. The fund is administered by QEW, which is a (IRS 501 c 3) tax-exempt organization. In addition to helping to pay for vasectomies, we are grateful for donations. We hope that men who have taken advantage of the Men for Men Fund will make stipends available for other men by repaying the Fund as they are able. Personal Information: Name: _______________________________________ Phone: ___/___/____ Address: ________________________________________________________ City: _____________________________ State: ____ ZIP: ________ Friends Meeting or Church that you belong to or attend: ___________________ Your surgeon's name: __________________________ Phone: ___/___/____ Address: ________________________________________________________ City: _____________________________ State: ____ ZIP: ________ Your Age: _____ years; Number of children you've fathered (optional): ______ Would you like to explain why you want the vasectomy? (optional): ________ ________________________________________________________________ Insurance information: Do you have any health insurance? [ ] YES [ ] NO If you do have insurance, does it cover vasectomy? [ ] YES [ ] NO If you don't have insurance now, do you expect to have health insurance in the next three months? [ ] YES [ ] NO Would you have difficulty, or be unable to afford a vasectomy if Men for Men didn't help pay for it? [ ] YES [ ] NO Signed: ___________________________ Date: ___/___/___
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