Hemorrhoids Online Registration

Hemorrhoids Online Registration Form

There are many advantages to use online registration form.

You are completely informed after online registration.
It will save your time on the day of your consultation and/or procedure.
You are able to provide the accurate information in the privacy of your own home or office.
We are able to review your history before you arrive and to call you if there are any medical or social concerns.

This site is secure and your information is kept confidential. This registration form must be completed by the patient only.

Instructions

To schedule a surgical procedure, a non-refundable and non-transferable deposit, $420 for self pay patients and $100 for insured patients, is required of all patients. We accept Visa or MasterCard credit/debit card only. This is credited toward your actual surgery cost. If you cancel or re-schedule for any reason, your deposit will not be refunded, and you have to pay new same deposit if you re-schedule your surgical appointment.
Fill in the Online Registration and Deposit Form and click "Submit". Fields marked * are Required Fields.
After registering, we will call you within 2 business days of receiving your registration.

Required Information

Patient Information
* Patient Name :
* Gender :	M F
* Date of Birth :	day month year
* Address :	City: State: ZIP:
* Email Address :
* Please re-enter your Email Address to confirm:
* Phone :	()--
* Social Security Number :	()--
Employer :
* Occupation :
How Did You Hear About Us :
* Marital Status :	Single Relationship Married
* Allergies to Medications :	Yes No If yes, please describe:
* Are You Currently Taking Any Medications :	Yes No If yes, please describe:
* Medical History :	Yes No If yes, please describe:
* Surgical History :	Yes No If yes, please describe:
* Family History :	Yes No If yes, please describe:
* Current Symptoms :
* Have you had any colonoscopy done?	Yes No When:

* The information above is correct. I authorize release of any medical information necessary that an insurance company may request to process a claim if I seek reimbursement. I request payment of insurance benefits to myself. I understand and accept that I am responsible for any and all charges incurred for professional services rendered to me. I also understand and accept that I am responsible for any charges incurred should collection proceedings become necessary to enforce this agreement.
Insurance Information
* Self Pay :	Yes, No, I will use the following insurance
Note :	$420 initial consultation fee for the self pay hemorrhoids patients. $100 registration fee for the insured patients, which will be credited toward your actual cost.
Insurance Company Name :
Insurance ID # :
Insurance Group # :
One Time Credit Card Payment Authorization Form
Sign and complete this form to authorize One Stop Medical Center to make a one time debit to your credit card listed below. By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account. I have read and understand all paragraphs of this document. I, * (full name), authorize One Stop Medical Center to charge $420 for the self pay hemorrhoids patients or $100 registration fee for the insured patients from my credit account indicated below on or after * (date). The payment of $100 registration fee is for the deposit of a surgical procedure. * Billing Address * City * State * ZIP * Phone ( )-- * Email
* Account Type: Visa MasterCard * Cardholder Name * Credit Card Number * Expiration Date /(Format: MM/YYYY) * CVV2 (3 digit number on back of Visa/MC)
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
* Signature Date

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