Baby Circumcision Registration

Child Information

Baby's Name*

First Last

Date of Birth*

Medicare Card Number (if available)

Healthcare Card Number (if available)

Parent Information

Mother's Name*

First Last

Mother's Medicare Card Number

Mother's Healthcare Card Number (if available)

Father's Name*

First Last

Father's Medicare Card Number

Father's Healthcare Card Number (if available)

Address*

Residential Address Suburb City State Post 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.

Allergies

Does your son have any allergies?*

Yes
No

If yes, please describe:

Referral Contacts - Optional

Family Physician / Pediatrician Name

First Last

Phone

City

Referring Healthcare Professional Name

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 the Royal Australian College of Physician and Paediatrics does not support routine infant circumcision.

*

We understand that we are making a consent by proxy for our infant for a non-therapeutic procedure. By submitting this form, we give our consent to this procedure as parents of this child.

*

We agree to have our son circumcised at Gentle Procedures Clinic. By completing this form, we have given our consent to this procedure as parents of this child.

*

We understand that complications can occur, although the frequency varies with the skill and experience of the doctor, and are infrequent with the Pollock Technique™. Complications 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 (never in this practice)
- More serious complications including death (never in this practice)

*

We understand that we must not not given any anti-inflammatory medications to our son in the 7 days prior to circumcision. Examples: ADVIL, IBUPROFEN, ASPIRIN, etc.

Comments

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

Baby Circumcision Registration