IMPORTANT – PLEASE READ

  1. Please fill out this online registration form before calling the clinic.
  2. You won't be charged until we call you for scheduling.
  3. Neither of our clinics accepts any medical insurance plans. However, if you have insurance and wish to seek reimbursement for your medical expenses, we’d be happy to provide an itemized billing statement once your care is completed.

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

 

Instructions

  1. Review the following information before completing your registration: Vasectomy General Information and Vasectomy in Our Practice. These pages provide helpful information about procedure cost and pre- and post-vasectomy instructions.

    2.  

  2. Pre-payment is required to schedule an Easy Vasectomy®: $690 for the Florida clinic or $790 for the Minnesota clinic. If you cancel or reschedule more than 7 days before your scheduled procedure, $100 of the pre-payment will be retained, and the remaining balance ($590 for Florida or $690 for Minnesota) will be refunded or credited. Cancellations within 7 days of the procedure or failure to show up will result in forfeiture of the full pre-payment.

    3.  

  3. Complete the Online Registration and Pre-Payment Form and click "Submit". After clicking Submit, please allow a few minutes for processing before attempting to submit again.

    4.  

  4. After we receive and process your registration, we will contact you to schedule your appointment. Please allow a few days for this process.

    5.  

  5. Patients under the age of 30 who have no children must first have a consultation with Dr. Shu. After the consultation, a 30-day waiting period is required before the procedure can be scheduled.

    6.  

  6. Please purchase two scrotal supporters (jockstraps) before your procedure. Please refer to the pre- and post-vasectomy instructions for details.

Required Information

    * Required fields

Personal Information

* Patient's Full Legal 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 you check regularly, and remember to check your junk or spam folder for our responses.

* 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 significant 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.

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

Please note the pre-payment will not be charged until you have an appointment scheduled.

Sign and complete this form to authorize Procedure Clinic 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 Procedure Clinic to charge my credit card account indicated below for $690 in Orlando FL office, or $790 in Minneapolis MN office on or after * (date). This payment is for the pre-payment of a vasectomy procedure.

* 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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