Baby Circumcision Registration

Child Information
Baby's Name*
First Last
Date of Birth*
DD slash MM slash YYYY
Healthcare Card Number
Parent Information
First Parent's Name*
First Last
Second Parent's Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Preferred Phone*
Preferred Email*
How did you hear about us?*
- Online / Google
- Paediatrician / Doctor's Referral
- Friend / Family Member
- Facebook / Instagram
Reason for circumcision*
- Cosmetic
- Cultural
- Ritual
- Religious
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):*
If breastfeeding, please list any medications you are taking (name/dosage):*
If the mother is taking any form of blood thinner (Dalteparin, ASA) you will need to call the office to speak with our doctor 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 (1/400)
  - 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 (1/1000)
  - Meatal stenosis or narrowing of the urethra (1/1000)
  - 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)
*
- 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 a late cancellation or no-show will result in the loss of the deposit. *
First Parent's Signature:
Second Parent's Signature
Comments
This field is for validation purposes and should be left unchanged.

Baby Circumcision Registration

Child Information

Parent Information

Medical History

Referral Contacts - Optional

Circumcision Consent

Gentle Procedures

Services

Appointments