Hemorrhoids Online Registration

Hemorrhoids Online Registration Form

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Note:
1. Please fill out this online registration form before calling the clinic.
2. You won't be charged until we call you for scheduling.
3. Neither of our clinics accepts any medical insurance plans. However, if you have insurance and wish to seek reimbursement for your medical expenses, we’d be happy to provide an itemized billing statement once your care is completed.

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 and/or procedure.
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

To schedule a hemorrhoids appointment: A $470deposit is required to reserve your hemorrhoid consultation. If you cancel or reschedule, $100 will not be refunded, and $370 will either be refunded or credited. A new $100 deposit is required to reschedule.
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

Patient Information
* Patient Name :	First Name Middle Name (Optional) Last Name
* Gender :	M F
* 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
* Allergies to Medications :	Yes No If yes, please describe:
* Are You Currently Taking Any Medications :	Yes No If yes, please describe:
* Medical History :	Yes No If yes, please describe:
* Surgical History :	Yes No If yes, please describe:
* Family History :	Yes No If yes, please describe:
* Have you had any colonoscopy done?	Yes No When:
Current Rectal Symptoms :
* Bleeding :	Yes No
* Pain :	Yes No
* Itching :	Yes No
* Bulging out :	Yes No
Others :

* 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.
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 $470 from my credit account indicated below on or after * (date). This payment is for the deposit of a hemorrhoid consultation or a procedure or a surgery. 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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