- Gentle Procedures Toronto

Infant Circumcision Registration Form

"*" indicates required fields

Step 1 of 3

33%

Company

This field is for validation purposes and should be left unchanged.

Patient Information

Patient Name (As indicated on Health Card)*

First Last

Date of Birth*

DD slash MM slash YYYY

Health Card Number (If available)

Parent/Legal Guardian Information

Parent/Legal Guardian Name*

First Last

Parent/Legal Guardian Name*

First Last

Preferred Telephone Number*

Preferred Email Address*

Medical History

Has your child had any medical or bleeding problems, or blood loss, since birth?*

Yes

If yes, please describe:

Were there any significant problems for baby or parent during delivery?*

Yes

If yes, please describe:

Did your baby receive a Vitamin K injection at birth?*

Yes

If you are unsure, you must confirm with your healthcare provider before booking, as our clinic requires all infants undergoing circumcision to have had a vitamin k supplement

Medications

Please list any medications your baby is currently taking:*

If breastfeeding, please list any medications, including over the counter pain medications, you are taking (name/dosage):*

If the breastfeeding parent is taking any form of blood thinner (ASA) you must advise our office prior to your baby’s appointment. Breastfeeding parents will need to stop taking blood-thinners and/or anti-inflammatory such as Advil, Motrin, Asprin, Ibuprofin etc. 7 days prior to baby's procedure with the permission of their prescribing healthcare provider. Tylenol is safe for pain management during this time.

Healthcare Provider Information

Family Physician / Nurse Practitioner/ Pediatrician

First Last

Telephone Number/ Fax Number

Referring Healthcare provider name (If different from above)

First Last

Telephone Number/ Fax Number

How Did You Hear About Us?*

Online / Google

Paediatrician / Doctor's Referral

Friend / Family Member

Facebook / Instagram

Other

Please specify*

Reason For Circumcision*

Cosmetic

Cultural

Religious

Other

Please specify*

Circumcision Consent Form, Please Check Each Point:

I/We have carefully considered the risks and benefits of this procedure and have discussed them with our family physician or other healthcare professionals. *

I/We understand that we are making consent by proxy for our infant for a non-therapeutic procedure. By signing this form, we have given our consent to this procedure as legal parent(s)/guardian(s) of this child. *

I/We understand that if one parent/legal guardian is not present for the circumcision, we must provide written consent from the absent parent acknowledging that there is agreement from both parents/legal guardians to proceed with the procedure. *

I understand that if I am the sole legal parent/guardian of the patient mentioned above, I must provide written confirmation of this. *

I/We understand that complications after circumcision can occur, although the frequency varies with skill and experience of the doctor and are infrequent in Dr. Sing’s practice. Potential complications may include: *

Significant post-op bleeding (1/400)

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 (1/1,000)

Meatal stenosis or narrowing of the urethra (1/1,000)

Sub-optimal cosmetic outcome (1/500)

Trauma to the head of the penis (1/40,000)

Injury to the urethra including urethra-cutaneous fistula (1/1,000)

More serious complications including death (1/1,000,000)

I/We confirm that we have not given any anti-inflammatory medications to my/our child within the last 7 days Examples: ADVIL, IBUPROFEN, ASPIRIN, MOTRIN, etc. *

I/We understand that late cancellation (less than 24 hours notice) /no-show will result in the loss of the deposit. *

I/We understand that arriving to the appointment unprepared according to the pre-operative instructions that have been provided at the time of booking, and included in the booking confirmation email will result in a cancelled appointment and forfeited deposit. *

I/We understand that arriving late to the appointment may result in a cancelled appointment and forfeited deposit. *

I/We understand that any appointment that is cancelled by the clinic due to any reason other than outlined above will be rescheduled at no additional cost. *

Electronic Consent Form

Dr. Roland Sing and his staff at Gentle Procedures Clinic Toronto, regularly communicate with and provide patients with their services through electronic communication and internet technology, such as email, text messaging (including instant messaging), and/or electronic medical records (EMR) portal. I hereby acknowledge and agree to the following:

1. Risks of using electronic communication

The physician will use reasonable means to protect the security and confidentiality of information sent and received using the Services outlined in this consent. However, because of the risks outlined below, the physician cannot guarantee the security and confidentiality of electronic communications:

Use of electronic communications to discuss sensitive information can increase the risk of such information being disclosed to third parties.
Despite reasonable efforts to protect the privacy and security of electronic communication, it is not possible to completely secure the information. Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.
Electronic communications can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, and security settings.
Electronic communications are subject to disruptions beyond the control of the physician that may prevent the physician from being able to provide services.
Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the physician or the patient.
Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.
Electronic communications may be required to be disclosed in accordance with law, a court order or other legal process. The exceptions to confidentiality include, but are not limited to, addressing imminent risk of serious harm to self or others; providing information in response to a subpoena or court order; providing information required by legislation (e.g. SGI or WCB), and as otherwise permitted under The Local Authority Freedom of Information and Protection of Privacy Act or The Health Information Protection Act.
Video conferencing using no cost, publicly available services may be more open to interception than other forms of videoconferencing.
There may be limitations in the services that can be provided through electronic communications, dependent on the means of electronic communications being utilized.
Email, text messages, and instant messages can more easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients.
Email, text messages, and instant messages can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has been sent.

2. Conditions of Using Electronic Communications

While the physician will endeavor to review electronic communications in a timely manner, the physician cannot provide a timeline as to when communications will be reviewed and responded to.
If your electronic communication requires or invites a response from the physician and you have not received a response within a reasonable time period, it is your responsibility to follow up to determine whether the intended recipient received the electronic communication and when the recipient will respond.
Electronic communication is not an appropriate substitute for in-person or over-the-telephone communication or clinical examinations, where appropriate, or for attending the Emergency Department when needed. You are responsible for following up on the physician’s electronic communication and for scheduling appointments where warranted.
Electronic communications concerning diagnosis or treatment may be printed or transcribed in full and made part of your medical record. Other individuals authorized to access the medical record, such as staff and billing personnel, may have access to those communications.
The physician may forward electronic communications to staff and those involved in the delivery and administration of your care. The physician might use one or more of the Services to communicate with those involved in your care. The physician will not forward electronic communications to third parties, including family members, without your prior written consent, except as authorized or required by law.
You agree to inform the physician of any types of information you do not want sent via the Services. You can add to or modify the above list at any time by notifying the physician in writing.
Some Services might not be used for therapeutic purposes or to communicate clinical information. Where applicable, the use of these Services will be limited to education, information, and administrative purposes. The physician is not responsible for information loss due to technical failures associated with your software or internet service provider. [check all that apply]:

Sexually transmitted disease

AIDS/HIV

Mental health

Developmental disability

Substance abuse

Other

Please specify

3.Instructions for communication using the Services

Reasonably limit or avoid using an employer’s or other third party’s computer.
Inform the physician of any changes in the patient’s email address, mobile phone number, or other account information necessary to communicate via the Services.

If the Services include email, instant messaging and/or text messaging, the following applies:

Include in the message’s subject line an appropriate description of the nature of the communication (e.g. “prescription renewal”), as well as your child’s full name and date of birth in the body of the message.
Review all electronic communications to ensure they are clear and that all relevant information is provided before sending to the physician.
Ensure the physician is aware when you receive an electronic communication from the physician, such as by a reply message or allowing “read receipts” to be sent.
Take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.
Withdraw consent only by email or written communication to the physician.
If you require immediate assistance, or if your condition appears serious or rapidly worsens, you should not rely on the Services. Rather, you should call the Physician’s office or take other measures as appropriate, such as going to the nearest Emergency Department or urgent care clinic.

4. Acknowledgement and Agreement

4. Acknowledgement and Agreement*

I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected electronic communications as described above. I understand and accept the risks outlined above to this consent form, associated with the use of the electronic communications with the physician and the physician’s staff. I consent to the conditions and will follow the instructions outlined above, as well as any other conditions that the physician may impose regarding electronic communications with patients. I acknowledge and agree to communicate with the physician or the physician’s staff using these electronic communications with a full understanding of the risks in doing so. *

I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that communications with the physician or the physician’s staff using the Services may not be encrypted. Despite this, I agree to communicate with the physician or the physician’s staff using these Services with a full understanding of the risk. I acknowledge that either I or the physician may, at any time, withdraw the option of communicating electronically through the Services upon providing written notice. *

I confirm that any questions that I had regarding the provision of healthcare services through electronic communications have been answered by the physician or delegate. *

I consent to having physician Dr. Roland Sing and his staff, through the Gentle Procedures Clinic Toronto, communicate with and/or provide me with their services through electronic communication and internet technology, such as email, text messaging (including instant messaging), and/or electronic medical records (EMR) portal. *

Parent/Legal Guardian Signature:*

Date*

DD slash MM slash YYYY

Parent/Legal Guardian Signature:*

Date*

DD slash MM slash YYYY

Infant Circumcision Registration Form

Patient Information

Parent/Legal Guardian Information

Medical History

Medications

Healthcare Provider Information

Circumcision Consent Form, Please Check Each Point:

Electronic Consent Form

Gentle Procedures

Services

Appointments