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.
  • 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 General Information Page  and Vasectomy in Our Practice page in this website. These pages contains helpful financial information and instructions for before and after vasectomy.
  2. Watch counseling video. (Dr. Shu was personally trained by Dr. Stein, and he uses the same techniques as Dr. Stein uses.)
  3. Choose the locations: Edina or Shoreview
  4. To schedule a vasectomy, a deposit of $100 (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.) The deposit is fully refundable until 7 calendar days prior to the appointed vasectomy date, non-refundable thereafter for either cancellation or postponement. If we receive payment from your insurance company, your deposit will be refunded less deductibles and co-payments.
  5. Fill in the Online Registration and Deposit Form and click "Submit". Fields marked * are Required Fields.
  6. After registering, please call our office (952-922-2151) to discuss available appointment times and set a date, or we will call you within 2 business days of receiving your registration. If the office is closed when you call, leave a message and we will return the call on the next business day.
  7. 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 :

*

Physical Exertion Level at Work :

Light      Moderate     Heavy*

PCP Name :

Clinic Name :

Clinic Address :

Clinic Phone Number :

()-

How Did You Hear About Us :

*

Marital Status :

Single     Relationship     Married*

Total Children :

*

Age of Youngest Child :

Were Pregnancies Planned :

Yes    No

Birth Control Method Using Now :

*

Wife/Girlfriend Name :

Wife/Girlfriend Aware :

Yes    No*

Ok to Communicate With Partner :

Yes    No*

Year With Partner :

Is Partner Pregnant Now :

Yes    No

Children With Partner :

Partner’s Total Children :

Allergies to Medications :

Yes    No*  If yes, please describe:

Are You Currently Taking Any Medications :

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.

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.

 

I have read and understand all paragraphs of this document.

Patient’s Signature     Date *

 

      

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