Online Account Registration

The information you enter MUST MATCH YOUR PROVINCIAL HEALTH CARD EXACTLY! Please take a moment to look at your card now to make sure you complete your registration accurately. The information on your health card MUST be up to date. Do not abbreviate names like Joe instead of Joseph. If you do not complete the health card information accurately we cannot submit the claim to provincial health. You may then be charged the full cost of your surgery.

Please fill in the information below:

Basic Information

First name

Last name

DOB: (MM/DD/YYYY)

Registration Number (MB Only 6-digit)

PHIN # (9 digit for MB patients/do not include space)

Phone

Mobile Phone

Additional Information

Address

Postal code

City

Province

Re-enter Email

Password

Re-enter password

Online questionnaire

1. How old are you?

2. Do you have a steady partner? If not, go to question #9

3. How old is she?

4. What is the TOTAL number of years you have been together?

5. How many children have you had with just her?

6. How may children does she have from a previous relationship?

7. Is she pregnant?

8. If yes, in what month is she expecting?

Was this a planned pregnancy?

9. How may children do you have from a previous relationship?

10. Have you ever fainted before? (This doesn't include being knocked out or having seizures)

11. If yes; approximately how many times?

Did it ever have anything to do with needles or doctors?

12. Do you anticipate having any problems with having surgery done in the office? Do you think you are likely to faint or be extremely anxious? (we realize that everyone is a bit anxious were referring to EXTREME)

13. Do you have any bleeding disorders (hemophiliac)?

14. Who do you work for and what type of work do you do? (Does it require lifting or prolonged standing? Explain in a few words. Example Manitoba Hydro, I am a lineman. It involves a lot of standing)

15. List any previous problems or surgery in the scrotal or groin area, such as hernia operations, twisting of a testicle (torsion), undescended testicle, surgery for a varicose vein or hydrocele etc. even if it was in childhood.

16. Are you taking any blood thinners such as Aspirin or Coumadin?

If yes, which one?

17. List any allergies to medications

18. Additional Information

19. Waist line (inches)

20. Weight (pounds)

Please review the information that you entered. If you are satisfied you can click on the Submit button to submit your registration

I consent to receive email correspondences from Dr. Billinkoff using this return email address.