Esgar Guarin MD Vasectomy Iowa

World Vasectomy Day – Iowa 2020.

Vasectomy ONLY $400

1. PERSONAL INFORMATION
First Name*
Last Name*
Email*
Age*
Primary contact phone (Mobile/Cell)*
2. INSURANCE INFORMATION
- I DO NOT HAVE or DO NOT WISH to use my insurance for this procedure
- I would like to use my INSURANCE
ACCEPTING CURRENTLY ONLY: Aetna, Coventry, Cigna, Midlands, Wellmark BCBS
3. VASECTOMY LOCATION AND DATE PREFERENCES
Preferred location*
* $400 cost of the vasectomy will be honored for those patients who get their vasectomy done between December 3-10, 2020 at the Mobile Vasectomy Clinic.
By submitting this form, you will be contacted by SimpleVas® Vasectomy Clinic to schedule your vasectomy. Procedures will ONLY be completed between December 3 and December 10, 2020 at the Mobile Vasectomy Clinic in one of the locations noted above.*
- I read, agree with, and understand the statement above
Please type your full name below (electronic signature)*
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