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Hemorrhoids Online Registration

Vasectomy | Reversal | Hemorrhoid Care | Adult Circumcision | Skin Surgery | Cysts | Lipoma | Nail | Varicose Veins
Online Registration Form | Hemorrhoids | Treatments | Hemorrhoid Treatment | Sphincterotomy | Anal Fistula | Anal Tag Removal | Anal Wart Removal | Botulinum Toxin Injection | Anorectal 101 | Cost
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

  1. 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.
  2. 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.
  3. 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 First Name :
Patient Middle Name :
* Patient Last Name :
* Gender : M    
* 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 is checked regularly.
* 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.

Insurance Information
* Self Pay : Yes  No
Note: $440 deposit for the self pay hemorrhoids patients. $100(consultation) or $250 (one banding or IRC treatment) or $500 (external hemorrhoidectomy) deposit for the insured patients with deductibles, $100 deposit for the insured patients without deductibles, which will be credited toward your actual cost.
   If pay with medical insurance, please provide :
* Insurance Company Name :
* Insurance ID # :
* Insurance Group # :
Note: We no longer accept insurance at our Florida office, and we only accept BCBS at the Blaine office.
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 $440 for the self pay hemorrhoids patients, or $100(consultation) or $250 (one banding or IRC treatment) or $500 (external hemorrhoidectomy) for the insured patients with deductibles, or $100 deposit for the insured patients without deductibles, from my credit card 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 /
* 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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