Easy VasectomyⓇ Online Registration | Minneapolis | MN | Orlando

Easy VasectomyⓇ | Easy Vasectomy ReversalⓇ

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 :	()--
* Social Security Number :	()--
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 # :
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 $590 (self-pay patients in Orlando office) or $100 (all the other patients) on or after * (date). This payment is for the deposit 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