Hemorrhoid Online Registration

Hemorrhoids Online Registration Form
BACK TO MAIN MENU

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

  1. To schedule a surgical procedure, a $100 non-refundable and non-transferable fee (payable by Visa or MasterCard credit/debit card only) is required of all patients. (If you do not have a credit card account, pre-paid Visa/MasterCards are available at many stores.) This is credited toward your actual surgery cost. If you cancel or re-schedule for any reason, your $100.00 will not be refunded, and you have to pay new deposit of $100 if you re-schedule your surgical appointment.
  2. Fill in the Online Registration and Deposit Form and click "Submit". Fields marked * are Required Fields.
  3. 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 :

()--

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

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 my credit card account indicated below for $100 on or after * (date). This payment is for the deposit of a surgical procedure.

 

* Billing Address * City    * State * ZIP

* Phone          ( )--             * Email  

* Account Type: Visa     MasterCard

* Cardholder Name    

* Account 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

 

      

BACK TO MAIN MENUtop

 
Copyright © 2015 One Stop Medical Center. All Rights Reserved.