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Easy Adult Hydrocelectomy™ Online Registration

Vasectomy | Reversal | Hemorrhoid Care | Adult Hydrocele | Adult Circumcision | Skin Surgery | Cysts | Lipoma | Nail | Varicose Veins
Online Registration Form | Adult Hydrocele | Techniques | Cost | Pre & Post Instructions

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.

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.
  • 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.

 

Instructions

  1. Please read the Hydrocele Information Page in this website. These pages contains helpful cost information and instructions for before and after hydrocelectomy.
  2. To schedule a consultation only, a $180 non-refundable and non-transferable fee is required. We accept Visa or MasterCard credit/debit card only. This is credited toward your actual consultation 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 appointment.
  3. Fill in the Online Registration and Deposit Form and click "Submit". Fields marked * are Required Fields.
  4. 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.
  5. You don't need to buy an athletic supporter, we provide you a free athletic supporter.

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 : ()--
* Social Security Number : ()--
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 Hydrocelectomy? 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.

Insurance Information
* Self Pay : Yes  No
   If pay with medical insurance, please provide :
* Insurance Company Name :
* Insurance ID # :
* Insurance Group # :
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 $180 to schedule a consultation on or after * (date). This payment is for the deposit of a hydrocelectomy consultation. 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 /
* 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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