¿Cómo funciona un pago de prueba?

form test

The following forms and corresponding instructions have been provided for your convenience. Please note that these forms may not be the appropriate forms for all patients in all circumstances. Formas en Español Debe usted completar el registro del paciente antes de su primer cita. Necesita usted impremir el registro del paciente, completarlo, y traerlo a su cita.

SERVICES
Select service*
Preferred appointment date
MM slash DD slash YYYY

Format: mm/dd/yy
Preferred appointment time*
- Morning
- Afternoon
PATIENT INFORMATION
Name*
First Last MI
Date of birth*
MM slash DD slash YYYY

Format: mm/dd/yy
Gender*
Address*
Street Address ZIP / Postal Code
Home phone #*
Cell phone #*
Patient contact email*
RESPONSIBLE PARTY (OR INSURED) INFORMATION
- The same as patient
Name*
First Last MI
Date of birth*
MM slash DD slash YYYY

Format: mm/dd/yy
Gender*
Home phone #*
Cell Phone #*
Patient relatIonship to the responsible party*
Payment
Total Cost
Hidden
Deposit
Total Cost
Hidden
Deposit
Total Cost
Hidden
Deposit
Deposit Quantity*
Price: $1,000.00
Deposit Payment
$0.00
Remaining Balance
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
PROCEDURE POLICY
Procedure: Circumcision Policy
Procedure: Newborn Circumcision Policy
Procedure: Vasectomy Policy
- Patient is responsible for paying full cost of $1000.00 for procedure.
- Patient must be completely shaved in genital area prior to arriving to appointment.
- Patient must AVOID taking any medication that contains Aspirin-Ibuprofen, it is important to stop these medications 1 week before the procedure to prevent abnormal bleeding.
- Contact our office BEFORE taking any medications.
No Show/Cancellation Policy

If you need to cancel or reschedule your appointment, please advise our office 48 hours prior the appointment date, in order to avoid any cancellation fee.
- Patients who fail to show for their scheduled procedure appointment and did not notify the office within 48 hours of their scheduled surgery appointment time, shall be subject to a “No Show/Cancellation” penalty of $500.00. If cancelled by the physician as a medical necessity, then the patient is not subject to this charge.
- These fees are not covered by insurance and is therefore the sole responsibility of the patient.
How to Cancel Your Appointment

To cancel or reschedule appointments please call our office at (305)266-2424 at least 48 hours prior appointment date. If you have any problems getting through, you can leave a message via phone, email, or patient portal with your name, appointment date and cancellation reason or request for rescheduling.

If you have more questions, please do not hesitate to ask one of our representatives at HealthCare Now.

By signing below, I acknowledge that I have read and understand HealthCare Now’s “Cancellation/No show” procedure policy.
- Patient responsible party is responsible for paying full cost of $250.00 for procedure.
- Patient must AVOIDtaking any medication that contains Aspirin-Ibuprofen, it is important to stop these medications 1 week before the procedure to prevent abnormal bleeding.
- Contact our office BEFORE taking any medications.
No Show/Cancellation Policy

If you need to cancel or reschedule your appointment, please advise our office 48 hours prior the appointment date, in order to avoid any cancellation fee.
- Patients who fail to show for their scheduled procedure appointment and did not notify the office within 48 hours of their scheduled surgery appointment time, shall be subject to a “No Show/Cancellation” penalty of $125.00. If cancelled by the physician as a medical necessity, then the patient is not subject to this charge.
- These fees are not covered by insurance and is therefore the sole responsibility of the patient’s responsible party.
How to Cancel Your Appointment

To cancel or reschedule appointments please call our office at (305)266-2424 at least 48 hours prior appointment date.

If you have any problems getting through, you can leave a message via phone, email, or patient portal with your name, appointment date and cancellation reason or request for rescheduling. If you have more questions, please do not hesitate to ask one of our representatives at HealthCare Now.

By signing below, I acknowledge that I have read and understand HealthCare Now’s “Cancellation/No show” procedure policy.
- Patient is responsible for paying full cost of $400.00 for procedure. (If patient has medical insurance, we will bill insurance directly, however patient is responsible for any balances the insurance does not cover).
- Patient must be completely shaved in genital area prior arriving to appointment.
- Patient must avoid taking any medication that contains Aspirin-Ibuprofen, it is important to stop these medications 1 week before the procedure to prevent abnormal bleeding.
- Contact our office BEFORE taking any medications.
No Show/Cancellation Policy

If you need to cancel or reschedule your appointment, please advise our office 48 hours prior the appointment date, in order to avoid any cancellation fee.
- Patients who fail to show for their scheduled procedure appointment and did not notify the office within 48 hours of their scheduled surgery appointment time, shall be subject to a “No Show/Cancellation” penalty of $200.00. If cancelled by the physician as a medical necessity, then the patient is not subject to this charge.
- These fees are not covered by insurance and is therefore the sole responsibility of the patient.
If you have more questions, please do not hesitate to ask one of our representatives at HealthCare Now.

How to Cancel Your Appointment

To cancel or reschedule appointments call our office at (305)266-2424 at least 48 hours prior appointment date. If you have any problems getting through, you can leave a message via phone or email, with your name, appointment date and cancellation reason or request for rescheduling.

By signing below, I acknowledge that I have read and understand HealthCare Now’s “Cancellation/No show” procedure policy.
Patient/Responsible Party Signature*
Signature date*

Format: mm/dd/yy
Comments
This field is for validation purposes and should be left unchanged.

Contact Us

Office hours

¿Cómo funciona un pago de prueba?

form test

SERVICES

PATIENT INFORMATION

RESPONSIBLE PARTY (OR INSURED) INFORMATION

Payment

PROCEDURE POLICY

Procedure: Circumcision Policy

Procedure: Newborn Circumcision Policy

Procedure: Vasectomy Policy

No Show/Cancellation Policy

How to Cancel Your Appointment

No Show/Cancellation Policy

How to Cancel Your Appointment

No Show/Cancellation Policy

How to Cancel Your Appointment