Baby Circumcision Registration

Child Information

Baby's Name*

First Last

Date of Birth*

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

Other

Reason for circumcision*

Please specify*

Medical History

Has the baby had any medical or bleeding problems, or blood loss, since birth?*

Yes

Does your family have any history of bleeding problems?*

Yes

If yes, please describe:

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

Yes

If yes, please describe:

Medications

Please list any medications your son is taking (name/dosage):*

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 (Dalteparin, ASA) you must advise our office prior to your baby’s appointment. Breastfeeding parents will need to stop taking anti-inflammatory medications, such as Advil, Motrin, Asprin, Ibuprofin etc. 7 days prior to baby's procedure. Tylenol is safe for pain management during this time.

Contact Information - Please complete as much detail as you can:

Family Physician / Pediatrician

First Last

Phone

City

Referring Healthcare Professional

First Last

Phone

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 provide written consent from the absent 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 skill and experience of the doctor and are infrequent in Dr. Sing’s practice. 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 confirm that we have not given any anti-inflammatory medications to our son within the last 7 days. 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

Name

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

Baby Circumcision Registration

Child Information

Parent Information

Medical History

Medications

Contact Information - Please complete as much detail as you can:

Circumcision Consent

Gentle Procedures

Services

Appointments