Easy Vasectomy Reversal® Online Registration

Easy Vasectomy Reversal® Online Registration Form

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.

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 vasectomy reversal.
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

Please read the Vasectomy Reversal General Information Page and Vasectomy Reversal in Our Practice page in this website. These pages contains helpful cost information and instructions for before and after vasectomy reversal.
To schedule a vasectomy reversal, a $990.00 non-refundable and non-transferable fee (payable by Visa or MasterCard credit/debit card only) is required of all patients. This is credited toward your actual surgery cost and we do NOT charge you this deposit until you have an appointment scheduled. Submitting the registration form does not submit any payment. If you cancel or re-schedule for any reason, your $990.00 will not be refunded, and you have to pay new deposit of $990 if you re-schedule your surgical appointment.
*** Please note that the card used for the deposit will be kept on file and used to get the remaining balance at the 2 week mark unless stated otherwise by the patient. If the attempt for the deposit is made and the card is declined, and the balance is not payed off by 5PM that day the surgery will be cancelled and the deposit will be lost. Please note it is the patients responsibility to be on top of their payments.
*** PAYMENT IS DUE IN FULL EXACTLY 2 WEEKS BEFORE PROCEDURE DATE.
Fill in the Online Registration 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.
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 :	Month Day 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
* Date of Vasectomy :	(Year)
* 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
* Did you have any sperm aspiration for IVF (in vitro fertilization) before?	Yes No *If yes, which procedure did you have? TESA PESA MESA Other
* Any other type of testicle/scrotal surgery?	Yes No If yes, please describe:
* Prior vasectomy or prior vasectomy and reversal?	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 Vasectomy Reversal Fact Sheet.
Consent for Vasectomy Reversal
I, the undersigned, request that Steven Shu, M.D. perform vasectomy reversal as an attempt to re-establish my fertility. I understand that the procedure may fail to restore sperm to my ejaculate and that, even if sperm reappear, there is no guarantee that I will be able to father a child. I also understand that my partner could be a future source of our infertility even though she may have undergone a rather thorough evaluation prior to my own vasectomy reversal. Although reasonable precautions are being taken, I may develop a blood clot in my scrotum, which could leave a tender lump within the scrotum for a prolonged period of time. To minimize chances of infection, I will take the antibiotic pills provided. I understand that if this procedure fails, it could be reattempted but that subsequent attempts are more difficult and less likely than the first to achieve successful results. I understand that Dr. Shu does not accept payment from any insurance companies, whether or not he is a contracted provider, for vasectomy reversals done in his office. While I may attempt to receive reimbursement, I will not now or at any time in the future attempt to involve an insurance company for payment of this service to Dr. Shu. I also understand that any lab work done outside of this office will be at my own expense.
* 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 $990 on or after * (date). This payment is for the deposit of a vasectomy reversal procedure. 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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