Hemorrhoids Online Registration

* Patient Name :

* Gender :

M    F

* Date of Birth :

month day year

* Address :

City: State: ZIP:

* Email Address :

* Please re-enter your Email Address to confirm:

* Phone :

()--

Employer :

* Occupation :

How Did You Hear About Us :

* Marital Status :

Single     Relationship     Married

Yes    No  If yes, please describe:

Yes    No  If yes, please describe:

Yes    No  If yes, please describe:

Yes    No  If yes, please describe:

Yes    No  If yes, please describe:

Yes    No  When:

Current Rectal Symptoms :

* Bleeding :

Yes    No

* Pain :

Yes    No

* Itching :

Yes    No

* Bulging out :

Yes    No

* 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.

Yes,     No, I will use the following insurance

Note :

$440 deposit for the self pay hemorrhoids patients. $100(consultation) or $250 (one banding or IRC treatment) or $500 (external hemorrhoidectomy) deposit for the insured patients with deductibles, $100 deposit for the insured patients without deductibles, which will be credited toward your actual cost.

Insurance Company Name :

Insurance ID # :

Insurance Group # :

Note: 1. We no longer accept insurance at our Florida office, and we only accept BCBS and Aetna at the Blaine office.

2. For patients with insurance, please take a picture of your medical insurance card and upload the images after you submit this online registration. Or click the link to do the upload now.

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 $440 for the self pay hemorrhoids patients, or $100(consultation) or $250 (one banding or IRC treatment) or $500 (external hemorrhoidectomy) for the insured patients with deductibles, or $100 deposit for the insured patients without deductibles, from my credit account indicated below on or after * (date). This payment is for the deposit of a hemorrhoid consultation or a procedure or a surgery. Please note this deposit will not be charged until you have an appointment scheduled.

* 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.