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Areas Served
Apache Junction, AZ
Avondale, AZ
Buckeye, AZ
Carefree, AZ
Cave Creek, AZ
Chandler, AZ
El Mirage, AZ
Fountain Hills, AZ
Gilbert, AZ
Glendale, AZ
Goodyear, AZ
Mesa, AZ
Peoria, AZ
Phoenix, AZ
Scottsdale, AZ
Surprise, AZ
Tempe, AZ
Tolleson, AZ
Queen Creek, AZ
Wickenburg, AZ
Contact
1
Progress - 60% Completed
2
Progress - 90% Completed
3
Progress - 95% Completed
Patient Name
*
First
Last
Date of Birth
*
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Age
*
Height
*
Weight
*
Phone
*
Patient's Email
*
Patient's Address
*
City
*
State
*
Zip
*
Would you like us to send your prescriptions electronically to your pharmacy to be ready for pick up on your way home after surgery?
*
Yes
No
Pharmacy Name:
*
Pharmacy Address:
*
Pharmacy Zip Code
*
Are you completing this form for someone else?
*
No, I am the patient.
Yes
Relationship to Patient
*
INSURANCE AND PRIMARY CARE INFORMATION
Do you Have a Primary Care Provider?
*
Yes
No
Provider name/office
*
Do you have Medical Insurance?
*
Yes
No
Subscriber Name
*
First
Last
Subscriber Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Subscriber ID Number / Member ID
*
Insurance Company Name
*
Insurance Company Phone Number
*
Insurance Group Number (if applicable)
Employer's Name (if applicable)
MEDICAL INFORMATION
How Many Children Do You Have?
*
What Form Of Birth Control or Contraceptive Are You Using?
*
Are you taking any prescription or non-prescription medications?
*
Yes
No
Please list and explain
Medication
Reason for using medication
Are you presently under the care of a physician?
*
Yes
No
For what condition?
*
Have you ever been hospitalized or had a serious illness/operation
*
Yes
No
For what condition?
*
Allergic reaction to any drug, food, or substance
*
Yes
No
List
*
Cause
Reaction
Have you had abnormal bleeding
*
Yes
No
Please explain:
*
Do you have any blood disorder such as anemia, hemophilia, sickle cell anemia, HIV
*
Yes
No
Please explain:
*
Have you ever had treatment for a tumor or cancer
*
Yes
No
Please explain:
*
Are you taking any blood thinners? (for example aspirin, ibuprofen, Coumadin, Eliquis Plavix, Xarelto)
*
Yes
No
Please explain:
*
DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING DISEASES, PROBLEMS, OR CONDITIONS
Artificial heart valves, joints, pacemaker or penile implant?
*
Yes
No
Please explain:
*
Irregular heart beat
*
Yes
No
Please explain:
*
Stroke
*
Yes
No
Please explain:
*
Issues with your spleen
*
Yes
No
Please explain:
*
High blood pressure
*
Yes
No
Please explain:
*
Asthma
*
Yes
No
How often do you use an inhaler?
*
Ever had an emergency situation or hospitalized for asthma?
*
Respiratory problems, emphysema, bronchitis, tuberculosis, etc
*
Yes
No
Please explain:
*
Sleep apnea
*
Yes
No
Please explain:
*
Seizures, epilepsy, or neurological disorder
*
Yes
No
Please explain:
*
Diabetes
*
Yes
No
Type of Diabetes?
*
Last A1c #?
*
Date of last A1c?
*
Hepatitis, jaundice, or liver disease
*
Yes
No
Please explain:
*
Kidney trouble
*
Yes
No
Please explain:
*
Ever been seen for any issues with your testicles, penis, bladder kidneys?
*
Yes
No
Please explain:
*
Stomach ulcers or hyperactivity
*
Yes
No
Please explain:
*
Do you have a nervous/ psychiatric condition (including depression/ anxiety)
*
Yes
No
Please explain
*
Do you drink alcoholic beverages
*
Yes
No
Please specify frequency and amount
*
Do you smoke, vape, or use chew tobacco
*
Yes
No
Please specify frequency and type
*
History of drug or substance abuse
*
Yes
No
Please specify
*
Anything else you would like to tell your doctor?
Yes
No
Please explain
*
I HAVE READ AND UNDERSTAND THE ABOVE QUESTIONS. ALL QUESTIONS I HAD ABOUT THIS FORM HAVE BEEN ANSWERED. I UNDERSTAND IT IS MY RESPONSIBILITY TO FILL OUT THE FORM CORRECTLY AND COMPLETELY.
Patient’s Signature to be signed physically in office: ___________________________________________________
Name
First
Last
Name
This field is for validation purposes and should be left unchanged.
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Home
Our Process
Pricing
FAQs
Instructions
Videos
Reviews
Write A Review
Blog
Areas Served
Apache Junction, AZ
Avondale, AZ
Buckeye, AZ
Carefree, AZ
Cave Creek, AZ
Chandler, AZ
El Mirage, AZ
Fountain Hills, AZ
Gilbert, AZ
Glendale, AZ
Goodyear, AZ
Mesa, AZ
Peoria, AZ
Phoenix, AZ
Scottsdale, AZ
Surprise, AZ
Tempe, AZ
Tolleson, AZ
Queen Creek, AZ
Wickenburg, AZ
Contact
Purely Vasectomies
14231 N 7th St. Suite 3A
Phoenix, AZ 85022
T:
(844) 667-7376
E:
info@PurelyVasectomies.com