Vasectomy Reversal Scheduling Questionnaire

Vasectomy Reversal 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
Scheduling Reversal Surgery

If you are ready to schedule surgery then:
- Your Body Mass Index (BMI) must be below 40
- You will be required to pay in full for surgery within 24 hours of completion of phone scheduling with the nurse
- If you are financing all or part of your surgery then you should have made arrangements with one of the financing companies listed on our website before starting this scheduling.
Do not submit this form if your BMI is above 40 or you are unable to pay in full within 24 hours of phone scheduling with the nurse.

Please call our office with questions.

Steps You Will Need to Complete

If you are ready to schedule surgery then these are the steps you will need to take:
1. Complete this form and pay the scheduling fee when finished
2. A nurse will call you within 48 hours to complete scheduling over the phone
3. After the phone interview the nurse will email you surgery documents
4. Electronically return signed documents
5. Complete lab work (if required*) as soon as possible
6. Send full payment within 24 hours
* Most vasectomy reversal patients will not require lab work for reversal surgery. Preoperative lab work may be required depeding on your medical history.
THIS IS NOT THE CORRECT FORM!

If you would like to start a RPA then go the the Vasectomy Reversal Prepayment Account Section of our website and complete the Vasectomy Reversal RPA Questionnaire.
How will you be paying for your surgery? You can check more than one box if you are paying with several methods?*

Bank wire (preferred because the cost to you is less)Credit card or FSA/HSA/Advance Care card (3.99% charge fee)CareCreditOther forms of financing (ie United Medical)
If you are financing all or part of your surgery then you should have arranged financing from one of the finance companies listed on our website prior to submitting this form.
Card Owner

Please enter name and email address of the card owner without errors.
What is the legal name of the card owner paying for surgery?*

First NameMiddle NameLast Name
If the card owner is not the patient, then the card owner will need to be physically present with the patient at the time of surgery consultation visit.

The card owner will be required to sign a credit card authorization in the office on the day of the consultation appointment.
What is the email address of the card owner paying for surgery?*

Confirmation Emailexample@example.com
Financial Guarantor

Please enter name and email address of the person who is the financial guarantor for surgery financing.
If another person is using their name and credit score to pay for your surgery using their credit card, CareCredit, FSA/HSA/Advance Care Card, CareCredit card or financing your surgery then they are your financial guarantor :

The scheduling nurse will need their full legal name and email address because that person will need to sign your financial documents.

Your financial guarantor will need to be present during your consultation appointment to co-sign your financial contracts in person.
What is the legal name of the person (your financial guarantor) helping to pay for your surgery?*

First NameMiddle NameLast Name
What is the email address of the person (your financial guarantor) helping to pay for your surgery?*

Confirmation Emailexample@example.com
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
Desired Surgery Date
On what date would you like to have your surgery?

MonthDayYear
Date
You cannot consider your surgery date confirmed until:
- Your signed documents have been returned
- Your lab test results (if required) have been reviewed by our office
- Your full payment has been received by our office
DO NOT MAKE TRAVEL OR HOTEL ARRANGEMENTS UNTIL ALL OF THE ABOVE ITEMS HAVE BEEN COMPLETED
How many years has it been since your vasectomy procedure? Answer in whole numbers only, i.e. 7 years ago.*
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 procedures and recommends you consider going elsewhere for your vasectomy reversal procedure.
Do you have biological children? Have you ever fathered a pregnancy?*

NoYes
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 uncertainty about the chance of vasectomy reversal success.
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.*
If your BMI is over 40 you will not be able to have surgery until your BMI is less than 40

Do not submit this form.

Call and speak with a scheduling nurse for advice.

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

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 scrotal pain experienced since your vasectomy then we recommend you have vasectomy reversal with a Urologist who specializes in the treatment of Chronic Scrotal Pain.

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 had a previous vasectomy reversal surgery?*

NoYes
If you have previously had a vasectomy reversal and want a second vasectomy reversal 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 have a consult with 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 completed 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 easily 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
Do you take weight loss medication(s)?*

NoYes
If "yes" to weight loss medication(s) what medications do you take?
Do you take phentermine weight loss medication (also known as Adipex-P, Lomaira)?*

NoYes, I take this medication
Do you take semaglutide or (also knowns as Wegovy or Ozempic) or tirzepatide (also known as Mounjaro or Zepbound)?*

NoYes, I take one of these medications
If you take phentermine, semaglutide, or tirzepatide you will need to stop these medications 14 days (2 weeks) before surgery.

These medications can increase the chance of an anesthesia complication. You will need to stop these medications at least two (2) weeks before your surgery.
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 hematologist 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 was 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 herbal remedies or aspirin at least three (3) weeks before surgery. These medications can cause bleeding.

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 as a result of the vasectomy 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 or have you been diagnosed HIV infection?*

NoYes
Do you have or have you been diagnosed with Hepatitis? (mark no if Hepatitis A diagnosis in the past)*

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.
1. Anti-inflammatory ibuprofen 800mg
2. Narcotic pain medication
3. Nausea medication
Can you take ibuprofen medication? *

NoYes
If no, please explain.
Some patients occasionally request we do not prescribe narcotics (stronger pain medications).

We recommend you allow us to prescribe a narcotic for you to take after your surgery.

You are not required to fill or take the narcotic prescription but at least it will be available to you should you require a pain medication stronger than ibuprofen.

You will have to pick up the narcotic while in North Carolina. The prescription cannot be transferred across state lines.
Which narcotic pain medication would you like to be prescribed after surgery at our center?*

Oxycodone (stronger-similar to Percocet)Hydrocodone (milder-similar to Vicodin)Tylenol with Codeine (mildest)Other
Which anti-nausea medication would you prefer?*

Phenergan (promethazine) Least expensiveZofran (ondansetron) More expensiveOther
Your prescriptions will be electronically sent to a pharmacy near our office in Raleigh NC. Which pharmacy below would you prefer? Harris Teeter, CVS, and Walgreens have locations in North Hills Mall. We do not recommend Walmart (limits narcotics) or Costco (odd hours).*

Harris TeeterCVSWalgreens
We will electronically send your prescriptions to the pharmacy indicated above a week before your appointment.

You may recieve a text message from the pharmacy when you prescription has been filled.

The medication will be waiting for you upon your arrival to Raleigh.
Please bring your health insurance card with you when you travel to Raleigh for surgery. Electronic prescriptions for your post-operative medications will be sent to your indicated pharmacy in Raleigh nearest our office.
- Your health insurance should pay for these medications when filled at a local pharmacy.
- Please be advised: Medicaid or Medicare will only pay for prescription medications if the prescriptions are filled in the state where those cards were issued. Medicaid or Medicare outside of North Carolina will not pay for prescriptions in the state of North Carolina.
- Presciptions will only be sent to pharmacies in the Raleigh area.
- We will not send prescriptions out of state BEFORE surgery
- You may recieve a phone text from the pharmacy BEFORE your consultation appointment informing you that your medication has been filled.
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 take any of these medications for WEIGHT LOSS or DIABETES? Dulaglutide (Trulicity), Exenatide extended release (Bydureon bcise), Exenatide (Byetta), Semaglutide (Ozempic), Liraglutide (Victoza,) Saxenda)Lixisenatide (Adlyxin), Semaglutide (Rybelsus)?*

NoYes
If you take Dulaglutide (Trulicity), Exenatide extended release (Bydureon bcise), Exenatide (Byetta), Semaglutide (Ozempic), Liraglutide (Victoza,) Saxenda)Lixisenatide (Adlyxin), Semaglutide (Rybelsus) then you will need to....

Stop these medications two weeks before surgery because these medications can cause a higher risk of anesthesia complications.

Do not start these medications within two weeks of surgery.
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 Vasectomy Reversal Surgery
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 your surgery.

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

If we request preoperative testing or recommendations from a consulting specialist then those results need to be completed and sent to us as soon as possible but at least three (3) weeks before your surgery date.

If you wait to send us your labs within three (3) weeks of your scheduled surgery and there is a problem with your lab tests then your surgery will be postponed and cancellation/rescheduling fees may apply.
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 phone scheduling with the nurse.

Delays in completing lab work and having the results reviewed by our office is a common reason for patients having to cancel their surgeries.

Responsible Adult

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.
Name of your Responsible Adult*

First NameLast Name
Cell phone number of your Responsible Adult*
Please enter a valid phone number.
What is your relationship to your Responsible Adult? (i.e. partner, mother, father, friend)?*
If your responsible adult changes between scheduling and arrival then please let our office know.
Name of emergency contact not traveling with you for surgery.*

First NameLast Name
Phone number for emergency contact*
Please enter a valid phone number.
What is your relationship to your emergency contact? (i.e. partner, mother, father, friend)?*
If your responsible adult changes between scheduling and arrival then please let our office know.

Vasectomy Reversal Surgery Confirmation
You cannot consider your surgery date confirmed until:
1. Your phone scheduling interview with our nurse is completed.
2. All documents have been signed and returned.
3. Your preoperative testing results (if required) have been reviewed by our office.
4. Your surgery fee has been paid in full.
Once your scheduling interview is completed, all signed documents have been returned, and your surgery fee has been paid then it is safe to make hotel and travel arrangements.

If we uncover any high-risk medical conditions during the phone scheduling interview, we may determine you are not a safe surgical candidate for outpatient surgery under general anesthesia.

The scheduling fee is not refundable under any circumstance.

If you have something in your history you are concerned about you should call and speak with a nurse before submitting this form.

Vasectomy Reversal Scheduling Questionnaire

Card Owner

Financial Guarantor

Patient Information

Desired Surgery Date

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 Vasectomy Reversal Surgery

Semen Sample Testing After Vasectomy Reversal Surgery

Vasectomy Reversal Surgery Confirmation

Surgery Policies

Credit Card

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