Baby Circumcision Registration

Child Information
Baby's Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
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?*
- Online / Google
- Paediatrician / Doctor's Referral
- Friend / Family Member
- Radio
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
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 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
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Baby Circumcision Registration

Baby Circumcision Registration Form

Child Information

Parent Information

Medical History

Allergies

Referral Contacts - Optional

Circumcision Consent