Easy Vasectomy® Online Registration

Easy Vasectomy® Online Registration Form

BACK TO MAIN MENU

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.
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 General Information Page and Vasectomy in Our Practice page in this website. These pages contains helpful cost information and instructions for before and after vasectomy.
To schedule an Easy Vasectomy®
- For self-pay patients, the full payment of $640 (FL) or $790 (MN) is required. If you cancel or reschedule before surgery, you’ll lose $100 of your deposit. The remaining balance ($540 for FL, $690 for MN) will be refunded or credited. Cancellations within 7 days of the surgery or no-shows result in forfeiting the full pre-payment.
- For insured patients, a $400 deposit is required if you have deductibles, or $100 if you don't. The deposit is credited toward your surgery cost. Cancellations or rescheduling will forfeit the $100 deposit, and a new $100 deposit is required for rescheduling.
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.
Patients who are under the age of 30 years with no children, are required to have a consultation first with Dr. Shu. Once seen for a consultation the patient is required to wait 30 days, in order to book a procedure.
Visit a sports store or order at Amazon to purchase a scrotal supporter (jockstrap).

Required Information

* Required fields

Personal Information
* Patient Name :	First Name Middle Name (Optional) Last Name
* 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
* 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 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 Fact Sheet.
Insurance Information
* Self Pay :	Yes No, I will use the following insurance
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.
Consent for Sterilization
I, the undersigned, request that Steven Shu, MD perform a bilateral vasectomy, a procedure to produce obstruction of the vas deferens for the purpose of producing sterility. I understand there can be no absolute guarantee that this or any procedure will be successful. It is understood, however, that my semen will be checked following the operation. I understand that contraception must be practiced until there are no sperm present. I also understand that while the reversal success rate is quite good, it is not 100%, and vasectomy should therefore be considered a permanent or irreversible procedure. I recognize a small chance that I might have to come to Dr. Shu's office or go to a hospital for evaluation and treatment of a very rare complication. By consenting to vasectomy and accepting the risks outlined above, I release Dr. Shu from liability for time lost from work, salary unearned, and medical expenses incurred to treat complications.
* 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 $640 (self-pay patients in Orlando office) or $790 (self-pay patients in Minneapolis office), or $400 (insured patients with deductibles) or $100 (insured patients without deductibles) on or after * (date). This payment is for the deposit of a vasectomy 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

BACK TO MAIN MENUtop