Physician Notes
Patient Intake Form
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Patient Name
*
First Name
Last Name
DateTime
Patient Birth Date
*
January
February
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December
Month
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Day
2023
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1920
Year
Patient Height (ft'in")
*
Patient Weight (lbs)
*
Patient E-Mail
*
example@example.com
Primary Phone Number
*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
How did you hear about our clinic?
Please Select
Google Search
Facebook
Advertisement
Yelp
Referral
Other
Back
Next: Medical History
Medical History
Do you have a primary care physician?
Yes
No
Name of primary care physician
Primary care physician's phone number
Please enter a valid phone number.
Please list any allergies
Have you ever had (Please check all that apply)
Anemia
Asthma
Arthritis
Cancer
Gout
Diabetes
Emotional Disorder
Epilepsy Seizures
Fainting Spells
Gallstones
Heart Disease
Heart Attack
Rheumatic Fever
High Blood Pressure
Digestive Problems
Ulcerative Colitis
Ulcer Disease
Hepatitis
Kidney Disease
Liver Disease
Sleep Apnea
Use a C-PAP machine
Thyroid Problems
Tuberculosis
Venereal Disease
Neurological Disorders
Bleeding Disorders
Lung Disease
Emphysema
Have you ever had (Please check all that apply)
Lightheadedness/faint during a procedure or test
Abnormal bleeding or bruising
Issues with erection or ejaculation
A sexually transmitted disease
Epididymitis
Other sexual or testicular issue
Other illnesses:
Do you smoke?
No
0-1 pack/day
1-2 packs/day
2+ packs/day
Please share your surgical history here:
List all current medications
Anything else regarding your medical history?
Employment Information
Occupation
Level of exertion at work
Sedentary
Light
Moderate
Heavy
Very Heavy
Back
Next: Family
Family Information
Are you married or are you exclusive with a single partner?
Yes
No
How long have you been with your wife/girlfriend/partner?
Are you and your partner currently expecting a child?
Yes
No
Reason for choosing vasectomy
Please Select
I am done having children
I do not want to have children
Health reasons
Other
If you have any children, list their ages.
Are you interested in sperm storage, also known as cryopreservation?
*
Yes, I would like to review this during our consultation.
No, I am not interested.
Not sure, let's discuss during our consultation.
Back
Next
Insurance Information
Would you like us to bill insurance for your vasectomy?
No, I will pay out of pocket
Yes
Insurance Provider
Group Number
Member ID
Are you the policyholder?
Yes
No
Policyholder's Full Name
First Name
Last Name
Policyholder's Social Security Number
Signature
Thank you! Please sign digitally and submit this intake form.
After signing and submitting this form, you will be directed to our Online Scheduler. If no dates and times work for your schedule, you may close the window. Your information is safely stored in our system and we will be in touch with you to schedule your consultation at a more convenient time.
*
I understand
Do you prefer a consultation via video chat (Zoom) or phone call?
Video Chat (Zoom)
Phone Call
Patient Signature
Clear
Submit
Should be Empty: