Please note that an appointment for a consultation and procedure will require approximately two hours of scheduled time. For this reason, a 50% deposit is required at the time of scheduling. This deposit can be made via major credit card.
Following an online appointment request, our office will contact you by phone to finalize an appointment and secure a deposit. Please note that we are unable to place international phone calls and will therefore respond to international requests via email.
Please provide the following contact information: (Note: Existing patients, please provide only your first, last name, e-mail address.)
First Name: Last Name: Preferred Phone #: E-mail: Date of Birth (MM/DD/YY)
Please answer the following health questions, as it will determine our ability to provide you with an automated appointment. Do you have any known drug allergies?
Yes No
Are you currently taking any medications such as asprin, Advil, etc.?
Do you have any chronic medical conditions, such as diabetes, high blood pressure, etc.?
Do you require antibiotics before dental or other procedures?
If you answered "yes" to any of the above questions, please continue to complete this form and Dr. Cornell will be in touch with you to discuss your individual case.
What service(s) are you interested in?
Consultation & Procedure Consultation Only Other:
Are you afraid of needles?
Do you become faint at the sight of needles?
Are you comfortable with having the procedure done in the office using local anesthesia given by injection in the penis?
When would you like to see Dr. Cornell?
Which day is best for an appointment?
Monday Tuesday
How did you hear about our practice and/or which physician referred you?
By clicking "Submit Form" you understand that this information will be sent to us via confidential email on a non-secure server. You also are signifying that you have read and understand our Notice of Privacy Practices.
