Forms and privacy information
Download the forms requested by our office before your appointment. Completed paperwork may be emailed to becky.feist@pearlandurology.com.
New Patient Paperwork
Patient information, insurance details, medical and surgical history, medications, and review of systems.
General Consent for Vasectomy Care
Consent for vasectomy consultation, procedure-related care, follow-up, and semen-sample testing.
HIPAA Notice of Privacy Practices
How Texas Vasectomy Center may use and disclose protected health information and a summary of patient privacy rights.
Appointment, cancellation, and payment policies
Standard vasectomy cancellation and rescheduling
Please give the office at least one week’s notice before the scheduled procedure if you need to cancel or reschedule. With at least one week’s notice, you may cancel or reschedule without consequences.
The office does not charge an immediate fee or penalty when less than one week’s notice is given. However, a $200 deposit is required before the patient can be placed back on the vasectomy schedule.
The $200 deposit is returned if the patient proceeds with the vasectomy at the rescheduled date and time.
Open the standard cancellation and rescheduling policy (PDF)
Single-visit consultation and vasectomy refund policy
When the consultation and vasectomy are scheduled together in one visit, the consultation fee is $220 and is paid outside insurance. The vasectomy charge is submitted to insurance, and the patient remains responsible for the amount applied by the plan.
The office collects the $220 consultation fee plus the patient’s estimated insurance responsibility for the vasectomy when the appointment is scheduled.
If the appointment is canceled or rescheduled more than seven days before the appointment date, the payment is refunded in full.
Because a large block of time is reserved, single-visit consultation and vasectomy appointments cannot be rescheduled within seven days of the appointment.
Open the single-visit consultation and vasectomy refund policy (PDF)
Insurance estimates and patient responsibility
The office contacts the patient’s insurance company to obtain an estimate before medical services are provided. Insurance companies sometimes provide inaccurate information or later deny payment despite an earlier benefit quote.
The insurance quote is therefore an estimate, not a guarantee.
Patients remain responsible for deductibles, copays, coinsurance, and any other balance that their insurance plan does not pay.