Circumcision and Vasectomy Procedure Pre-Registration

First name

Last name

Phone

Country/Region

Address

City

Zip / Postal code

Patient's date of birth

Preferred date and time (not guaranteed)

Terms and Conditions:

Patient is responsible for paying balance of procedure upon arrival to your appointment, prior to the procedure being started
Patient must be completely shaved in genital area prior arriving to appointment.
Patient must avoid taking any medication that contains Aspirin or Ibuprofen or other blood thinners at least one week before the procedure to reduce risk of bleeding.
Registering and paying a deposit does not guarentee you are eligible for this procedure, if the doctor determines you are not a candidate, you will recieve a refund and the procedure will be cancelled.

No Show/Cancellation Policy: If you need to cancel or reschedule your appointment, please advise our office 48 hours prior the appointment date, failure to do so will result in a cancellation fee equal to your total deposit.

I agree to all terms and conditions above

I certify I weigh less than 250 LBS or that I have had a consult with the doctor and was approved for this procedure

I certify that I have not been diagnosed with Diabetes or high blood sugar, or that if so I have had a consult with the doctor and was approved for this procedure

Product

Adult Circumcision Deposit (Total price $1000)$750

Vasectomy Deposit (Total price $600)$200

Infant Circumcision Deposit (Total price $250)$125

Signature