Easy Vasectomy Reversal™ Online Registration Form
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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.

This site is secure and your information is kept confidential. This registration form must be completed by the patient only.

 

Instructions

  1. Please read the Vasectomy Reversal General Information Page  and Vasectomy Reversal in Our Practice page in this website. These pages contains helpful financial information and instructions for before and after vasectomy reversal.
  2. To schedule a vasectomy reversal, a $950.00 non-refundable and non-transferable fee (payable by Visa or MasterCard credit/debit card only) is required of all patients. (If you do not have a credit card account, pre-paid Visa/MasterCards are available at many stores.) This is credited toward your actual surgery cost. If you cancel or re-schedule for any reason, your $950.00 will not be refunded, and you have to pay new deposit of $950 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.
  3. Fill in the Online Registration and Deposit Form and click "Submit". Fields marked * are Required Fields.
  4. After registering, we will call you within 2 business days of receiving your registration.
  5. 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 :

Day Month 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

* 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 Name     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 $950 on or after * (date). This payment is for the deposit of a vasectomy reversal procedure.

* Billing Address * City    * State * ZIP

* Phone                ( )--                     * Email  

* Account Type: Visa     MasterCard

* Cardholder Name    

* Account 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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