Child & Teen Circumcision Registration

Child & Teen Circumcision Registration Form

Child Information
Child's Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Healthcare Card Number
Parent Information
Mother's Name*
First Last
Father's Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Preferred Phone*
Email*
Where did you hear about us?*
Medical History
Has your son 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.
Referral Contacts - Optional
Family Physician / Pediatrician
First Last
Phone
City
City
Referring Healthcare Professional
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 General Procedures Clinic offers circumcision on older children under local anesthesia and we were explained this approach.
*
- 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 parent 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)
  - Injury to the urethra including urethra-cutaneous fistula (1/1000)
  - More serious complications including death (never in this practice)
*
- We understand that our child is no longer in the newborn period and it may be necessary for the doctor to use some or all of the following modalities to stop any bleeding should it occur:
  - Pressure dressings
  - Skin glue
  - Bipolar cautery
  - Suturing
*
- 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.
*
- We understand that it may be necessary to restrain our child.
Name
This field is for validation purposes and should be left unchanged.

Boy and Teen Circumcision Registration

Child & Teen Circumcision Registration Form

Child Information

Parent Information

Medical History

Referral Contacts - Optional

Circumcision Consent