Easy Adult Circumcision™ Online Registration

Online Registration Form | Easy Adult Circumcision™ | Techniques | Cost | Pre & Post Instructions

Easy Adult Circumcision™ Online Registration Form

If you decide to schedule a procedure, please complete this online registration before calling the clinic. Your credit card will not be charged until you complete the scheduling process over the phone.

This site is secure and your information is kept confidential. This registration form must be completed by the patient only.

Instructions

Please read the Easy Circumcision™ Information Page in this website. These pages contains helpful cost information and instructions for before and after circumcision.

To schedule a vasectomy reversal, a total payment of $1,180 is required.
- This includes a $990 non-refundable, non-transferable surgical deposit and a $190 consultation fee. Payment is accepted by Visa or MasterCard (credit or debit) only.
- The deposit will not be charged until your appointment is confirmed. Submitting the registration form does not initiate any payment. The $990 deposit will be applied toward the total cost of your surgery.
- If you cancel or reschedule your surgical appointment for any reason, the $990 deposit will not be refunded, and a new $990 deposit will be required to secure another surgical date. The $190 consultation fee will be refunded if you cancel or reschedule.
*** PAYMENT IS DUE SEVEN BUSINESS DAYS BEFORE PROCEDURE DATE. ***

Fill in the Online Registration and Deposit Form and click "Submit". Fields marked * are Required Fields. Note: after clicking the Submit button, please wait a few minutes before attempting to retry.

After processing your registration form, we'll get in touch with you to schedule a suitable appointment. Kindly be aware that this process may take a few days.

Required Information

* Required fields

Personal Information
* Patient Name :	First Name Middle Name (Optional) Last Name
* Date of Birth :
* Address :	City: State: ZIP:
* Email Address :	Note: This will be the email address used for all future communications. Please ensure you are using an active account that you check regularly, and remember to check your junk or spam folder for our responses.
* Please re-enter your Email Address to confirm:
* Phone :	()--
Employer :
* Occupation :
How Did You Hear About Us :
* Marital Status :	Single Relationship Married
* Total Children :
* Wife/Girlfriend Aware :	Yes No
* Ok to Communicate With Partner :	Yes No
* Allergies to Medications :	Yes No If yes, please describe:
* Are You Currently Taking Any Medications :	Yes No If yes, please describe:
* Do you have any medical history :	Yes No If yes, please describe:
* Do you smoke, drink and use any drugs :	Yes No If yes, please describe:
* Do you have any significant family history :	Yes No If yes, please describe:
Have You Had Any of the Following :
* Hernia surgery as an infant or child?	Yes No
* Hernia surgery as an adult?	Yes No
* Surgery for undescended testicles?	Yes No
* Surgical removal of a testicle?	Yes No
* Surgery for torsion/twisted testicles?	Yes No
* Any other type of testicle/scrotal surgery?	Yes No If yes, please describe:
* Prior Circumcision?	Yes No If yes, please describe:
* Have you had any other operations?	Yes No If yes, please describe:
Have you had any of these problems?
* Bleeding :	Yes No
* Easy Bruising :	Yes No
* Fainting/lightheaded often :	Yes No
* Herpes :	Yes No
* Genital Warts :	Yes No
* Epididymitis :	Yes No
* Varicocele :	Yes No
* HIV/AIDS :	Yes No
* Difficulty getting or maintaining an erection :	Yes No
* Difficulty achieving climax :	Yes No
* Premature ejaculation :	Yes No

* The information above is correct. I authorize release of any medical information necessary that an insurance company may request to process a claim if I seek reimbursement. I request payment of insurance benefits to myself. I understand and accept that I am responsible for any and all charges incurred for professional services rendered to me. I also understand and accept that I am responsible for any charges incurred should collection proceedings become necessary to enforce this agreement.
Consent for Adult Circumcision
I, the undersigned, request that Steven Shu, MD perform a circumcision. I understand there can be no absolute guarantee that this or any procedure will be successful. I also understand that there's a low chance that I may have to come to Dr. Shu's office or go to a hospital for evaluation and treatment of a very rare complication. I was informed about the common complications, including bleeding, infection, wound healing issue, unfavorable scars, under or over skin excision, nerve damage, glan and urethra damage, ED or any psychological issue. By consenting to circumcision and accepting the risks outlined above, I release Dr. Shu from liability for time lost from work, salary unearned, and medical expenses incurred to treat complications.
* Patient's Signature Date
One Time Credit Card Payment Authorization Form
Sign and complete this form to authorize One Stop Medical Center to make a one time debit to your credit card listed below. By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account. I have read and understand all paragraphs of this document. I, * (full name), authorize One Stop Medical Center to charge my credit card account indicated below for $1,180 on or after * (date). This payment is for the deposit of a circumcision procedure. Please note this deposit will not be charged until you have an appointment scheduled. * Billing Address * City * State * ZIP * Phone ( )-- * Email
* Account Type: Visa MasterCard * Cardholder Name * Credit Card Number * Expiration Date /(Format: MM/YYYY) * CVV2 (3 digit number on back of Visa/MC)
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
* Signature Date

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