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Vasectomy Reversal Scheduling Questionnaire

The Vasectomy Reversal Surgery Scheduling Questionnaire can be found at the bottom of this page.

If you are having problems competing this form on-line we can email this form to you or you can by-pass this completely and you can schedule by phone directly with the nurse.

By completing this surgery scheduling questionnaire your health interview and surgery scheduling with the reversal nurse will be more efficient.

  1. Please complete and submit this Reversal Surgery Scheduling Questionnaire before paying your scheduling fee.
  2. 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.
  3. Please call at any time if you have questions.
  4. A nurse will only call you to schedule after your questionnaire has been completed, you have paid the scheduling fee, and we receive email confirmation your scheduling fee has been paid.
  5. 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. Surgery scheduling does not occur on weekends or after 5 pm East Coast time.
  6. Available surgery dates change frequently. Your surgery date can only be confirmed after you have completed the phone scheduling and your full surgery payment has been received.
  7. If you are financing any portion of the surgery you will need to know the amount of financing you qualify for before you start the scheduling process.

Vasectomy Reversal Surgery Scheduling

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