RPA - Vasectomy Reversal Scheduling Questionnaire
Language
  • English (US)
  • Spanish (Latin America)

  • Vasectomy Reversal Prepayment Account Scheduling Questionnaire

  • Are you scheduling Surgery or starting a Reversal Prepayment Account?*

  • THIS IS NOT THE CORRECT FORM FOR SCHEDULING VASECTOMY REVERSAL SURGERY!

    • This is a Reversal Prepaymant Account Form
    • If you would like to schedule surgery then please go to the scheduling section of our website and complete the Vasectomy Scheduling Questionnnaire

     

  • Starting A Vasectomy Reversal Prepayment Account

     Complete this form to start a Vasectomy Reversal Prepayment Account (RPA).

    • You will have three (3) years to save towards your surgery
    • We will email RPA members when discounted surgery rates are available

    You can start an RPA if your BMI is over 40, but you will not be able to schedule surgery until your BMI is less than 40. 

    Steps to Start an RPA

    If you are ready to start an RPA then these are the steps you will need to take:

    1. Complete this form and pay the scheduling fee 
    2. A nurse will call you within 48 hours to complete RPA scheduling over the phone
    3. The nurse will email you RPA contracts
    4. Electronically return all signed RPA contracts
    5. Complete required lab work (if required) as soon as possible
    6. Send your initial deposit. The minimum amount to start an RPA is $500

    You must electronically return signed RPA contracts and send the minimum deposit of $500 within 30 days of completing RPA phone scheduling.

    Please call the office if you need additional instructions.

  • Patient Information

    Please enter information as accurately as possible. Please enter your name, date of birth, and email address without errors.

  • Please use your legal name as it appears on your driver’s license or government issued identification.

  • Your date of birth*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Please use an email you check often.


  •

  • We recommend you avoid heavy lifting and bending for two (2) weeks after your reversal surgery.

    Ideally, you should avoid going to the gym, lifting weights, and strenuous excersise for four (4) weeks after reversal surgery.

  • In which language would you prefer to schedule surgery?*

  • If your vasectomy was greater than twelve (12) years ago then there is a 10% chance you would require a more complicated vasoepididymostomy procedure.

    This also known as a by-pass procedure where the upper big part of the vas deferens tube is attached to the lower small epididymis tube. This is a more complicated reversal procedure with a higher chance of failure.

    Dr. Monteith does not perform vasoepididymostomy, or by-pass, procedures and recommends you consider going elsewhere for your vasectomy reversal procedure.

  • Do you have biological children? Have you ever fathered a pregnancy?

  • If you do not have biological children or have never fathered a pregnancy then there is a chance you had an abnormal sperm count (low sperm count or no sperm) before your vasectomy.

    This increases the uncertainty on the chance of success of vasectomy reversal surgery.

  • Body Mass Index Calculator

    We require your BMI be less than 40 to have surgery at our center

  • You are permitted to start an RPA if your BMI is over 40. 

    You will not be able to schedule surgery until your BMI is less than 40

    All patients will have their height and weight measured and official BMI calculated during their consultation appointment.

    Often patients will enter incorrect information at the time of scheduling because:

    • They are not certain about their height or weight
    • They are over the maximal BMI limit and hope to lose weight before their surgery

    If you are over the BMI limit at the time of your consultation appointment your surgery will be cancelled and you will lose 100% of your surgery fee.

    Exceptions are never made to the BMI policy.

  • High Risk Medical Conditions

  • DO NOT SUBMIT THIS FORM if you have any of the high risk medical conditions in this section. 

    Call and speak with a nurse.

  • Are you on dialysis?*
  • Have you had an organ transplant?*
  • Do you have a heart defibrillator?*
  • Do you have a heart pacemaker?*
  • Have you ever had a myocardial infarction (heart attack)?*
  • Do you have a spinal cord stimulator or any other medical device implanted in your body?*
  • Do you have Myasthenia Gravis?*
  • Have you or a family member been diagnosed with Malignant Hyperthermia?*
  • Do you have Sickle Cell anemia (not Sickle Cell trait)?*
  • Do you personally have or is there a family history of Pseudocholinesterase Deficiency?*
  • Is it difficult to start an IV or draw blood on you? For example, do they have to use an ultrasound to start an IV or have a special doctor or IV team insert IVs or draw blood on you?*

  • Conditions Which Decrease The Chance Of Successful Vasectomy Reversal

  • DO NOT SUBMIT THIS FORM if you have any of the conditions below that may decrease the chance of a succesful vasectomy reversal. 

    Call and speak with a nurse.

  • Have you ever had chemotherapy for the treatment of cancer?*
  • Have you ever had testicular cancer?*
  • Have you ever had either chemotherapy or radiation treatment for testicular cancer?*

  • If you have previously been treated for testicular cancer with either chemotherapy or radiation then you are at higher risk of having impaired sperm production. You are at higher risk for having a failed vasectomy reversal.

     

    Please call the office to speak with a nurse.

  • Are you having your vasectomy reversed ONLY because you have experienced chronic scrotal pain since your vasectomy? Mark "No" if your main reason is to have more children*

  • If you are having your vasectomy reversed ONLY because of chronic pain experienced since your vasectomy then we recommend you have your vasectomy reversed with a Urologist who specializes in the treatment of Chronic Scrotal Pain.

    We would not consider you a candidate vasectomy reversal if your reason for reversal is solely for treatment of chronic scrotal pain.

    Please call our office if you have questions.

  • Have you had a previous vasectomy reversal surgery?*

  • If you have previously had a vasectomy reversal and are trying a second attempt then you have a much higher chance of having scar tissue, a more difficult surgery, and a failed vasectomy reversal.

    We would not consider you a candidate for an attempt at a second vasectomy reversal.

    Please call our office if you have questions.

  • Have you been diagnosed with male infertility before your vasectomy procedure?*

  • If you have been diagnosed with male infertility before your vasectomy then a vasectomy reversal may not be the best treatment to help you get pregnant.

    We recommend you see a male infertility specialist to discuss options other than reversal to help you father another child.

    Please call our office if you have questions.

  • The above conditions are high risk conditions.

    If you have any of the conditions above then STOP.

    Do not complete this form and do not pay the scheduling fee.

    Please call to speak with a Scheduling Nurse.

  • Conditions That May Result In Repair Of Only One Side

    The following are conditions which may result in only being able to repair one side during your surgery. Please call to discuss with a nurse before submitting this form.
  • Did you have any complications during or after your vasectomy procedure?*
  • Have you had a groin or inguinal hernia repair?*
  • Was your VASECTOMY done in an operating room AT THE SAME TIME as your HERNIA surgery was being performed?*

  • If you had a vasectomy at the same time as a hernia repair surgery then it is possible the vasectomy was performed at the site of the hernia repair (high in the abdominal wall).

     This means they could have done a one sided vasectomy in the scrotal area and done the other side of the vasectomy in the area where the hernia was repaired (high in the abdominal wall).

    If your vasectomy was done at the same time as the hernia repair then we will need you to request the surgical operative report describing the surgery so we can see exactly what was done. You can send us the operative report for a free review before submitting this form.

    Please call if you have questions.

  • Do you currently have an undescended testicle that was diagnosed during childhood (this means your testicle is in your abdominal muscle, high in your abdominal wall, or high in your groin)?*
  • Have you had surgery as an infant, child, or teenager for an undescended testicle (cryptorchidism)?*

  • If you have an undescended testicle or have had surgery for an undescended testicle then it is likely that side will not be reversible.

    Please call and speak to a nurse if you have questions.

  • Have you and your partner had in-vitro fertility (IVF) treatment AFTER your vasectomy to try to become pregnant?*
  • After your vasectomy have you had Percutaneous Epididymal Sperm Aspiration (PESA) to help with IVF treatment? PESA is a procedure that requires a needle be inserted through the skin and into your epididymis to retrieve sperm for IVF treatment?*

  • PESA increases the chance you have addtional damage or blockage in the epdidymis. PESA increases the chance your vasectomy reversal may be more complicated and, in some cases, not possible on one or both sides.

    We would need to see the surgical operative report describing the PESA procedure to better determine if you are a good candidate for vasectomy reversal at our center.

    Please call our office if you have questions.

  • Medical History

  • Are you currently on a prescription blood thinning medication (not aspirin)?*
  • Have you ever been treated with blood thinning medications?*
  • Have you ever been diagnosed with a disorder that increases blood clots (i.e. Factor V Leiden, Antithrombin III, Protein C or S deficiency)?*
  • Have you ever had blood clots in your legs (deep venous thrombus or DVT) or lungs (Pulmonary embolus or PE)?*
  • Have you ever been diagnosed with a stroke?*

  • Blood Thinners, Blood Clots, Blood Clotting Disorders, Strokes

    If you are currently taking a prescription blood thinner, have been diagnosed with a DVT/PE, have a disorder that increases the risk of having a serious blood clot, or have had a stroke then you will need to have a consultation with a hematologist or your local doctor before you can schedule surgery.

    You should complete and submit this scheduling form.

    The Scheduling Nurse will provide more information and will send you a referral letter to take to a hematologist for their recommendations. 

    • If the hematologist does not recommend anti-coagulation (a blood thinner) then you can schedule surgery without any additional testing.
    • If the hematologist recommends anti-coagulation (a blood thinner) after surgery then they will need to provide you with the prescription and instructions on how to take the medication. You will also need to have a phone/office consultation with Dr. Monteith before you can compelte surgery scheduling.
    • If the hematologis recommends anti-coagulation before, during, and after surgery then you would not be considered a candidate for reversal surgery.
  • Have you ever been diagnosed with Lupus?*
  • Have you ever been diagnosed with Lupus complications (kidney disease, heart/lung/brain complications, low platelets, stroke, blood clots?*
  • Do you take any medications (prescription or over-the-counter medications)?*
  • Do you take herbal remedies or aspirin?*

  • You should stop these medications at least three (3) weeks before surgery. These medications can increase the chance of having a bleeding complication.

    You can use acetamiophen (Tylenol) or ibuprofen in limited amounts if needed.

    These medications do not increase the risk of bleeding.

  • Are you currently using hormones: testosterone or anabolic (muscle building) steroids?*

  • If you are taking testosterone or body building steroids then this temporarily decreases sperm production. This makes it harder to determine at the time of reversal if your body is producing viable sperm.

    When we perform vasectomy reversal we examine the fluid in the lower end for sperm.

    • If sperm are present this is a better indicator your reversal will be successful. 
      If sperm are not present present we never know if it is because your body has permanently stopped making sperm or if the hormones are temporarily causing your body to stop making sperm. 


    We recommend you stop these hormones at least three (3) months before reversal.

    This allows us to better examine the fluid, determine if sperm present, and may increase the chance of pregnancy success after reversal.

    These hormones decrease sperm production while you are taking them. This means if you restart these medications after reversal you may be lowering your sperm count.

    Most likely, you will not be able to resume these hormones until you have completed your fertility goals. 

  • Are you allergic to any medications (prescription or over the counter)?*
  • Do you have HIV infection?*
  • Have you ever had a Hepatitis infection?*
  • Do you currently have an active infection of any kind?*
  • Do you have any medical problems for which you are under the continual care of a physician?*
  • Have you ever had surgery?*

  • All patients are provided written prescriptions for pain and nausea medication during their stay in Raleigh North Carolina.

    1. Anti-inflammatory ibuprofen 800mg
    2. Narcotic pain medication
    3. Nausea medication

    These prescriptions will be sent to a Raleigh pharmacy before your consultation.

  • Have you had gastric by-pass surgery (any type)?*
  • Do you have asthma or problems breathing?*

  • You will need to bring any inhalers or breathing medications with you on the day of your consult and surgery.

  • Do you have sleep apnea (loud snoring with pauses in breathing while you sleep)?*
  • Do you have a CPAP machine?*

  • You will need to bring your CPAP machine with you on the day of your consult and surgery.

  • Do you have high blood pressure?*

  • You will need to bring your blood pressure medications with you to your consult and surgery.

  • Do you have diabetes?*

  • You will need to bring any diabetic medications with you on the day of your consult and surgery.

  • How do you manage your diabetes?*
  • Do you check your blood sugars?*
  • Do you have problems with your thyroid?*
  • Do you take thyroid medication?*

  • You will need to bring your thyroid medication with you on the day of your consult.

  • Lab Testing Before Starting A Vasectomy RPA

  • We do not require preoperative testing for most vasectomy reversal patients.

    Depending on your medical history, we may require preoperative testing or a letter of recommendations from a consulting specialist before you can open your vasectomy reversal RPA.

    A nurse will discuss this with you at the time of your phone interview.

     

  • Semen Sample Testing After Vasectomy Reversal Surgery

  • A confirmatory semen sample to confirm the reappearance of sperm is recommended three (3) to six (6) months after vasectomy reversal.

    Our office will perform this testing for you in our office at no charge. You can bring us a fresh sample or mail your sample to us.

    If you would like your semen tested at an outside lab after your vasectomy reversal then our office will provide you with the lab orders at the time of your surgery.

    You will be responsible for the cost of any testing performed at an outside lab.

  • It is extremely important you have your lab work completed as soon as you complete your RPA scheduling with the nurse.

  • Responsible Adult

    For planning purposes, you need to be aware a Responsible Adult will need to be with you during your preoperative consultation, the day of your surgery, and the day after surgery. This person must be above the age of 18.

    If you have another person paying for your surgery (financial guarantor) with a credit card or financing then this person must be with you during your consultation to sign our paperwork.

    The responsible adult will need to:

    • Be present during your consultation appointment
    • Remain in our facility the entire time you are having surgery
    • Help you get back to the hotel and take care of you the night of surgery
    • Help you get back to our office for your post-operative consultation
    • Help you travel back home

    If you do not have a responsible adult with you at your consultation appointment your surgery will be cancelled and you will forfeit your entire surgery fee.

  • Vasectomy RPA Confirmation

  • You can not consider your RPA completed until:

    • You return your signed RPA contracts
    • Your initial RPA deposit has been received

    You have thirty (30) days to complete your RPA from the time the nurse completes your RPA phone interview.

    If you do not return your signed contracts and make your initial deposit then you will have to repay the scheduling fee and restart the RPA process.

    The scheduling fee is not refundable under any circumstance.

    It you have something in your history you are concerned about you should call and speak with us before submitting this form.

  • RPA Policies

    By checking each box below you are acknowledging you understand each policy.
  • Format: (000) 000-0000.
  • Clear

  • Surgery Scheduling Fee: You cannot pay this fee with CareCredit*

    prevnext( X )
    Reversal Prepayment Account (RPA) Scheduling Fee. Non Refundable
    Reversal Prepayment Account (RPA) Scheduling Fee

    Non Refundable

    $180.54$180.54
      
    Total
    $0.00$0.00

    Payment Methods

    creditcard
  • Is the credit card being used to submit this form in the patient's name or another person's name?*
  • Should be Empty: