Lutz - Main Office
VasWeb Doctors Online Vasectomy Registration:
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Demographic Information
* First Name
* Last Name
Middle Initial
Preferred Name (How you prefer to be addressed)
* Mailing Address
* City
* State
* Zip Code
* Phone 1
Phone 2
* Preferred Contact Phone
* Email
* Date of Birth

Insurance Information
Use your insurance card to fill out this form. Add any extra phone numbers or other information on your card into the final field. Please bring your insurance card to the office when you come for your appointment.
* Insurance Company Name
* Claims Street Address
* Claims City, State & Zip
* Claims Phone Number
* Policy # or Insured/Member ID
* Group Number (enter n/a if no group number)
Policy Holder (If Other Than Patient)
Other Information About Insurance