Registration Form

Registration Form
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Preferred Apointment time (not guarenteed)
Terms and Conditions:
- Patient is responsible for paying balance of procedure upon arrival to 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.

My Products

Adult Circumcision Deposit Total cost $1000

$750.00

Newborn Circumcision DepositTotal cost =$250

$125.00

Vasectomy DepositTotal cost $600

$200.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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

yes
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*

yes
Signature

Powered by Jotform SignClear
Should be Empty: