Vasectomy Reversal Prepayment Account
Scheduling Questionnaire
The Vasectomy Reversal Prepayment Account Prescheduling Questionnaire can be found at the bottom of this page.
If you are having problems completing this form on-line we can email this form to you or you can by-pass this completely and schedule by phone directly with the nurse.
By completing this questionnaire and the nurse interview, you can then start your Reversal Prepayment Account with greater confidence you will be a good candidate for tubal surgery. You will also be in a better position to more quickly take advantage of any reduced rate surgeries should they become available.
- Please complete and submit this Reversal Prescheduling Questionnaire before paying your scheduling fee.
- If you do not have all of the information requested in this questionnaire you are welcome to skip those sections. You can provide the required information to the nurse at the time of your phone scheduling.
- Please call at any time if you have questions.
- A nurse will only call you to conduct your health interview after your questionnaire has been completed, you have paid the scheduling fee, and we receive email confirmation your scheduling fee has been paid.
- After you submit this form and pay your scheduling fee, a scheduling nurse will call you within 1 to 2 business days to schedule your surgery. Phone interviews do not occur on weekends or after 5 pm East Coast time.
After completing this questionnaire and the nurse phone interview, you can then send in your initial contribution. This prescheduling process will allow you to save towards your surgery with greater confidence you will be the best candidate possible when you are ready to schedule. Since you have obtained medical clearance, you will also be able to more quickly take advantage of any reduced surgery rates should they become available.
Reduced rates will only be offered to Reversal Prepayment Account members.
