Easy Adult Circumcision™ Online Registration Form
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There are many advantages to use online registration form.

  • You are completely informed after online registration.
  • It will save your time on the day of your consultation and/or circumcision.
  • You are able to provide the accurate information in the privacy of your own home or office.
  • We are able to review your history before you arrive and to call you if there are any medical or social concerns.

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

 

Instructions

  1. Please read the Easy Circumcision™ Information Page  in this website. These pages contains helpful cost information and instructions for before and after circumcision.
  2. To schedule an Easy Circumcision™, a $950 non-refundable and non-transferable deposit is required. We accept Visa or MasterCard credit/debit card only. This is credited toward your actual surgery cost. If you cancel or re-schedule for any reason, your deposit will not be refunded, and you have to pay new same deposit if you re-schedule your surgical appointment.
  3. Fill in the Online Registration and Deposit Form and click "Submit". Fields marked * are Required Fields.
  4. After registering, we will call you within 2 business days of receiving your registration.

Required Information

    * Required fields

Personal Information

* Patient Name :

* Date of Birth :

day month year

* Address :


City: State: ZIP:

* Email Address :

* 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.

* I have read the Circumcision Fact Sheet.

Insurance Information

* Self Pay :

Yes    No, I will use the following insurance

Insurance Company Name :

Insurance ID # :

Insurance Group # :

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 recognize a small chance that I might have to come to Dr. Shu's office or go to a hospital for evaluation and treatment of a very rare complication. 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 $950 on or after * (date). This payment is for the deposit of a circumcision procedure.

* Billing Address * City    * State * ZIP

* Phone          ( )--             * Email  

* Account Type: Visa     MasterCard

* Cardholder Name    

* Account 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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