Vasectomy Intake Form

Physician Notes
Patient Intake Form

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Patient Name*

First NameLast Name
DateTime
Patient Birth Date*

MonthDayYear
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 NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
How did you hear about our clinic?

Family Information
Are you married or are you exclusive with a single partner?

YesNo
How long have you been with your wife/girlfriend/partner?
Are you and your partner currently expecting a child?

YesNo
Reason for choosing vasectomy
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.

Insurance Information
Would you like us to bill insurance for your vasectomy?

No, I will pay out of pocketYes
Insurance Provider
Group Number
Member ID
Are you the policyholder?

YesNo
Policyholder's Full Name

First NameLast 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
Should be Empty:

Patient Intake Form