Online Vasectomy Registration
Advantages
1. Saves time - This is precisely the information that we have always asked each patient to provide on the day of his visit. By registering online before your visit, you will not have to fill out a similar form on the day of your consultation and/or vasectomy.
2. Accuracy of information - By registering in the privacy of your own home or office, you will not be distracted by other activity within our office on the day of your visit. You may also have access to medical information (prior surgeries, medications, names of doctors) that you may not recall on the day of your visit. Plus we can read it ... on the handwritten info sheets completed in our office, you'd be surprised how many 4's look like 9's and 9's look like 7's! This site is secure and your information is kept confidential.
3. Peace of mind that there will be no surprises on the day of your visit because you are completely informed and prepared. In fact, so much is learned online that a preliminary consultation visit is not required.
4. Safety - Pre-registration gives Dr. Stein and his staff the opportunity to review your history before you arrive and to call you if there are any medical or social concerns, especially important for those patients who waive the option of a preliminary visit.
Instructions 
1. Please read the Vasectomy Information Page in this website. This page contains helpful financial information and instructions for before and after vasectomy.
2. It may be information overload, but we will also ask you to view our counseling video before your procedure. It is available here online as a small streaming video and at our Tampa office and outfield locations as the full screen DVD version.
3. Think about where and when you would like to have your vasectomy. At the Tampa office, (1) we can work directly with your insurance company if we are a contracted provider, (2) you can have your procedure on almost any Tuesday, Thursday, or Friday afternoon, and (3) you can usually have the procedure within a few days of your call. At our other locations (see schedule), (1) we may not be able to bill your insurance company directly (however we will provide a properly coded receipt which you may submit to your carrier), and (2) dates and times are restricted to those in the schedule. Also, at county health department facilities, you must sign a consent form at least 30 days prior to the procedure. Keep in mind that you should recline on the evening of the vasectomy and engage in no strenuous activity the next day (no yard work, sports, or lifting over 20 pounds). On the following day, you may walk and drive and return to work if your job is not strenuous.
4. To schedule, a deposit of $100 (payable by Visa or MasterCard credit/debit card only) is required of all patients except those whose procedures are funded through a county health department. (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 Registration and Deposit Form below and click "Submit". Fields marked * are Required Fields. The information comes to our database as though we entered it ourselves from information provided by you in writing (as office forms) or by phone. It is secure and confidential. (In fact, your credit card information goes directly to Merchant Services and we have no access to it when you pay online.) Once we print your registration, we have your pertinent medical history and no need to have you fill out more forms. You will see the printout and have an opportunity to make changes on the day of your visit.
6.

After registering, please call our office (813-972-1365, 813-903-1902 or 866-827-8463) to discuss available appointment times and set a date, or we will call you within 2 business days of receiving your registration.

Helpful hints: You may fill in the form, moving from one field to the next by tapping the tab key. Return to a previous field by tapping the tab key as you hold down the shift key (shift+tab). If you follow the the suggestions in green, you should never have to use the mouse or touchpad. Alt+down-arrow means that you hold down the alt key as you tap the down arrow key.

Demographic Information
Last Name: *
First Name: *
Middle Initial:
Preferred Name (How you prefer to be addressed)
Street Address: *
City: *
State: *
Zip Code: *
If needed, may we send a medical follow-up letter to this address?  No  Yes *  (Arrow keys to select)
Home Phone: Area code ()- * XXX-XXXX
Cell Phone: Area code ()-   XXX-XXXX
Work Phone: Area code ()-   XXX-XXXX
Preferred Contact Phone: Home Cell Work * (Arrow keys to select)
E-mail address:
Date of Birth:  month (xx) day (xx) year (xxxx) *

Employment Information

Employer:
Occupation:
Level of exertion at work: *  (Arrow keys to select)
If moderate or heavy exertion, please plan on not working the next day. 

Vasectomy Location and Date Preferences

Preferred or already-scheduled location (see schedule):

  * (Alt+down-arrow to see all choices, up and down arrows to select) Note: The health department sites do their own scheduling.

Tampa Office (complete this if answer above is "Tampa office")
Preferred or already-scheduled date: --

Other Locations (complete this if answer above is NOT "Tampa office")
Preferred or already-scheduled date (see schedule): --

Primary Care Doctor Information

Do you have a Primary Care Doctor?

No   Yes *
Select your doctor below if present.
*
Please provide as much info as you can, at least last name and city.
Last Name: *

Degree:

First Name:
Address:
City: *

State:

Zip Code:
Do we have your permission to send a copy of your vasectomy report to your Primary Care Doctor so that your records with him/her are complete?  
Yes No
(Arrow keys to select)

OB/GYN Doctor Information

Does your wife or girlfriend have an OB/GYN?

No  Yes  No Partner  *
(Arrow keys to select)
Select your wife or girlfriend's OB/GYN below if present.
Please provide as much info as you can, at least last name and city.
Last Name:

Degree:

First Name:
Address:
City:

State:

Zip Code:

Do we have your permission to send a copy of your vasectomy report to your wife's OB/GYN doctor so that her family planning records with him/her are complete?  

  Yes  No  (Arrow keys to select)

  

Medical Information

Have you ever had an allergic reaction to any medications?

 No  Yes *  (Arrow keys to select)

Please list the medications that have caused allergic reactions:

   

Do you take any prescribed medications?

 No  Yes *  (Arrow keys to select)

Please list your medications:

to treat
to treat
to treat

 Have you ever had any of these operations?
No  Yes * 
(Arrow keys to select)

If Yes, please check (tap spacebar) all that apply:

Hernia surgery as an infant or child
Hernia surgery as an adult
Surgery as a child for undescended testicle
Surgery for a torsion or twisted testicle
Removal of a testicle
Prior vasectomy or prior vasectomy and reversal
Any other type of scrotal or testis surgery
Please type the blue key word for any box that you checked:
   

Have you ever had any other operations? No  Yes *
  
Please list:
   

Have you ever had any of these problems?
No  Yes *
(Arrow keys to select)

If Yes, please check (tap spacebar) all that apply:

Problems with bleeding or easy bruising
Difficulty getting or maintaining erections
Premature ejaculation
Difficulty reaching a climax
Tendency to get lightheaded or faint when having or witnessing medical procedures or tests.
Herpes
Genital warts
HIV
Epididymitis
Varicocele

   

Family Information
Your age: *
Marital status: * (Alt+down-arrow to see all choices, up and down arrows to select)
"Single" includes "divorced" and "never married".
Wife's or girlfriend's Full Name:
Your wife's or partner's permission is not necessary for your vasectomy,
but is she aware that you are having one? 		No  Yes * (Arrow keys to select)
May we communicate with her regarding vasectomy scheduling
and post vasectomy semen checks?		 No  Yes * (Arrow keys to select)
How you would refer to yourself with respect to your partner: * (Alt+down-arrow to see all choices, up and down arrows to select)
Your wife's or girlfriend's age: *
Number of years with your present wife or girlfriend: *
Number of children you have had with your present wife or girlfriend: *
Total number of children you have had: *
Total number of children your present wife or girlfriend has had: *
Age of your youngest child: *
Were your children all planned? *
Is your wife or girlfriend pregnant now? No  Yes * (Arrow keys to select)

Method(s) of birth control used over the past year 
(please check [tap spacebar] all that apply):

 None
Avoidance
Rhythm
Withdrawal
Vaginal (spermicidal) cream, foam, or film
Diaphragm
Condoms
Birth control pills
Depo shots
Birth control patches
Norplant
IUD
Other

PRIMARY method of birth control over the past few months:

* (Alt+down-arrow to see all choices, up and down arrows to select)

Referral Information

What was the PRIMARY source of referral to this office? >>>>

 * (Alt+down-arrow to see all choices, up and down arrows to select)

To reduce marketing and advertising costs,
please tell us how you found out that we do vasectomies at the location where you plan to have yours?
(please check [tap spacebar] all that apply)

 My primary care physician (PCP)
My wife's (partner's) OB/GYN doctor
Friend  (optional)
Internet search
Weekly Planet
The Flyer
Billboard
Bus bench
Insurance company
Health Department of    County 
Planned Parenthood (PP) clinic in the city of
Yellow pages for the city of 
Radio ad on station
Advertisement in the newspaper
Other

   

Confirmation of Preparation for Vasectomy
I have read and understand the Vasectomy Information Page of this website, which includes instructions to be followed before and after the vasectomy.  Yes  No * (Arrow keys to select)
I have watched the Vasectomy Counseling Video online.  Yes  No, I will watch it on a TV at the place where I will have the vasectomy *
I understand that I should not take any aspirin or aspirin-containing compounds for a week prior to my vasectomy.  Yes  No *

Privacy Policy  Email Disclaimer

 

Appointment Deposit
Is your vasectomy being paid for by a county health department?  Yes   No  *
Credit Card Information
Name as it appears on credit card *
Card Number *
Card Type *
Expiration Date * *
Phone *
Email Address *
Billing Address
Address Line 1 *
Address Line 2
City *
State *
ZIP *

We require a $100 deposit prior to scheduling your procedure. If you have insurance the difference will be refunded to you.

Clicking "Submit" acknowledges that you accept our privacy policy and email disclaimer. When you click Submit, your form will be submitted and your browser will take you back to the Home Page of this website. You may not receive a confirmation that the form was sent. When you arrive for your visit, you will have a chance to make changes and/or additions. You must still call our office (813-972-1365 or 866-827-8463)to confirm the date and arrange an appointment time. Thank you.