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| Toronto East - Scarborough, Ontario |
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Baby Circumcision Registration
Baby Circumcision Registration
Marwan Nasr
2017-03-09T12:32:49-04:00
Please complete the registration form below for baby circumcision.
Thanks for booking with us.
Baby Circumcision Registration Form
Child Information
Baby's Name
*
First
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
Healthcare Card Number
(if available)
Parent Information
Mother's Name
*
First
Last
Father's Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Preferred Phone
*
Email
*
How did you hear about us?
*
Medical History
Has your baby had any medical or bleeding problems, or blood loss, since birth? Does your family have any history of bleeding problems? Do you have any reason to believe that your son has low blood or low hemoglobin?
*
Yes
No
If yes, please describe:
Were there any significant problems for the child or mother when the child was born?
*
Yes
No
If yes, please describe:
Please list any medications your son is taking (name/dosage):
*
Type n/a if none
If breastfeeding, please list any medications you are taking (name/dosage):
*
Type n/a if none. Please note that if the mother is taking any form of blood thinner (Dalteparin, ASA) you will need to call the office to speak with one of our doctors prior to your appointment.
Referral Contacts - Optional
Family Physician / Pediatrician Name
First
Last
Phone
City
City
Referring Healthcare Professional Name
First
Last
Phone
City
City
Circumcision Consent
You must consent to the following:
*
We have carefully considered the risks and benefits of this procedure and have discussed them with our family physician or other healthcare professional.
*
We understand that we are making a consent by proxy for our son for a non-therapeutic procedure. By signing this form, we have given our consent to this procedure as parents of this child.
*
We understand that if one parent is not present, we must still show written consent from that parents acknowledging that there is agreement from both parents to proceed with the procedure.
*
We understand that complications after circumcision can occur, although the frequency varies with the skill and experience of the doctor, and are infrequent at Gentle Procedures Clinic. Complications may include:
Significant post-op bleeding (1/100)
Phimosis or narrowing of the shaft-skin opening over the head of the penis (1/500)
Buried or trapped penis in the abdomen (1/800)
Infection requiring antibiotics (1/1000)
Meatal stenosis or narrowing of the urethra (1/1000)
Sub-optimal cosmetic outcome (1/500)
Trauma to the head of the penis (never in this practice)
More serious complications including death (never in this practice)
*
We understand that our son must not have any anti-inflammatory medications in the 7 days prior to his procedure. Examples: ADVIL, IBUPROFEN, ASPIRIN, MOTRIN, etc.
Name
This field is for validation purposes and should be left unchanged.
Call us :
647-568-1512
|
COVID-19 INFO
WE ARE TEMPORARILY CLOSED.
The clinic is closed due to the current situation.
Existing patients may call Dr. Nguyen directly.
We hope to be open for new patients in the coming months.
Thanks.