RPA - Vasectomy Reversal Scheduling Questionnaire

Vasectomy Reversal Prepayment Account Scheduling Questionnaire
Are you scheduling Surgery or starting a Reversal Prepayment Account?*

Schedule surgery (Pick this option if you are ready to select a date and pay in full)Start 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 current legal name*

First NameMiddle NameLast Name
Your date of birth*

MonthDayYear
Date
What is your age?*
Home address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Cell phone number*
Please enter a valid phone number.
Home phone number (if no home phone then best number for us to reach you)*
Please enter a valid phone number.
Please use an email you check often.
Patient e-mail*

Confirmation EmailConfirm your email address
What is your occupation?
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?*

EnglishSpanishOther
How many years has it been since your vasectomy procedure?*
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?

YesNo
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
What is your weight in pounds?*
What is your height in feet and inches (example 5 feet 4 inches)?*
BMI Calculator: Enter your height in feet and inches (without shoes) and your weight in pounds into the BMI calculator below. Please answer honestly. Your height and weight will be officially confirmed at the time of your surgery consultation.*
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?*

NoYes
Have you had an organ transplant?*

NoYes
Do you have a heart defibrillator?*

NoYes
Do you have a heart pacemaker?*

NoYes
Have you ever had a myocardial infarction (heart attack)?*

NoYes
Do you have a spinal cord stimulator or any other medical device implanted in your body?*

NoYes
Do you have Myasthenia Gravis?*

NoYes
Have you or a family member been diagnosed with Malignant Hyperthermia?*

NoYes
Do you have Sickle Cell anemia (not Sickle Cell trait)?*

NoYes
Do you personally have or is there a family history of Pseudocholinesterase Deficiency?*

NoYes
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?*

NoYes
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?*

NoYes
Please explain the type of cancer and chemotherapy to the best of your ability:*
Have you ever had testicular cancer?*

NoYes
Have you ever had either chemotherapy or radiation treatment for testicular cancer?*

NoYes
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*

NoYes
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?*

NoYes
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?*

NoYes
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?*

NoYes
Please describe the complication(s)
Have you had a groin or inguinal hernia repair?*

NoYes
Was your VASECTOMY done in an operating room AT THE SAME TIME as your HERNIA surgery was being performed?*

NoYes
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)?*

NoYes
Have you had surgery as an infant, child, or teenager for an undescended testicle (cryptorchidism)?*

NoYes
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?*

NoYes
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?*

NoYes
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)?*

NoYes, I currently take a prescription blood thinner
Have you ever been treated with blood thinning medications?*

NoYes
Have you ever been diagnosed with a disorder that increases blood clots (i.e. Factor V Leiden, Antithrombin III, Protein C or S deficiency)?*

NoYes
Have you ever had blood clots in your legs (deep venous thrombus or DVT) or lungs (Pulmonary embolus or PE)?*

NoYes
Have you ever been diagnosed with a stroke?*

NoYes
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?*

NoYes
Have you ever been diagnosed with Lupus complications (kidney disease, heart/lung/brain complications, low platelets, stroke, blood clots?*

NoYes
What were the Lupus complication(s)?
Do you take any medications (prescription or over-the-counter medications)?*

NoYes
If yes, please list the names of the medications you take.
Do you take herbal remedies or aspirin?*

NoYes
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?*

NoYes
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)?*

NoYes
If yes, please list the names of the medications you are allergic to and what is your allergy symptom. For example, penicillin causes rash.
Do you have HIV infection?*

NoYes
Have you ever had a Hepatitis infection?*

NoYes
Do you currently have an active infection of any kind?*

NoYes
If yes, what kind of infection.
Do you have any medical problems for which you are under the continual care of a physician?*

NoYes
If yes, list all current medical conditions you have been diagnosed with by a physician.
Have you ever had surgery?*

NoYes
If yes, please list your surgeries.
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)?*

NoYes
Do you have asthma or problems breathing?*

NoYes
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)?*

NoYes
Do you have a CPAP machine?*

YesNo
You will need to bring your CPAP machine with you on the day of your consult and surgery.
Do you have high blood pressure?*

NoYes
You will need to bring your blood pressure medications with you to your consult and surgery.
Do you have diabetes?*

NoYes
You will need to bring any diabetic medications with you on the day of your consult and surgery.
How do you manage your diabetes?*

DietInsulin pumpInsulin InjectionsPillsOther
Do you check your blood sugars?*

NoYes
What are your fasting blood sugars (first thing in the morning before eating)?*
Do you have problems with your thyroid?*

NoYes
Do you take thyroid medication?*

YesNo
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.

Vasectomy Reversal Prepayment Account Scheduling Questionnaire

Patient Information

Body Mass Index Calculator

High Risk Medical Conditions

Conditions Which Decrease The Chance Of Successful Vasectomy Reversal

Conditions That May Result In Repair Of Only One Side

Medical History

Lab Testing Before Starting A Vasectomy RPA

Semen Sample Testing After Vasectomy Reversal Surgery

Vasectomy RPA Confirmation

RPA Policies

Credit Card

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