If you decide to schedule an office visit, 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 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 an Easy Vasectomy®
Self-Pay Patients: A $440 deposit is required to reserve your hemorrhoid consultation. If you cancel or reschedule, $100 will not be refunded, and $340 will either be refunded or credited. A new $100 deposit is required to reschedule.
Insured Patients with Deductibles: A $100 deposit is required to reserve your hemorrhoid consultation, $250 for each banding or IRC treatment, $500 for external hemorrhoidectomy. This is credited toward your surgery cost. If you cancel or reschedule, $100 of your deposit is non-refundable.
Insured Patients without Deductibles: A $100 deposit is required to reserve your hemorrhoid consultation and each procedure or surgery. This is credited toward your surgery cost. If you cancel or reschedule, the deposit is non-refundable.
Fill in the OnlineRegistration and Deposit Form and click "Submit". Fields marked * are Required Fields.
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.