Adult Circumcision Registration

Patient Information
Name*
First Last
Date of Birth*
YYYY dash MM dash DD
Address*
Street Address Address Line 2 City Province Postal Code
Preferred Phone*
Email*
Emergency Contact Name*
First Last
Emergency Contact Phone*
Family Doctor
First Name Last Name
Family Doctor's Phone Number
Family Doctor's Medical Centre or Workplace
How did you hear about us?*
- Online / Google
- GP / Doctor's Referral
- Friend or Family Member
- Radio
Allergies
Do you have any allergies?*
- Yes
- No
If yes, please describe:
Medical History
Do you have a history of easy bruising?*
- Yes
- No
Do you have nosebleeds with little or no trauma?*
- Yes
- No
Have you ever had abnormal or prolonged bleeding after a dental procedure?*
- Yes
- No
Did you have any medical or bleeding problems, or blood loss, since birth?*
- Yes
- No
Does your family have any history of bleeding problems?*
- Yes
- No
Do you have any reason to believe that you have low blood pressure or low hemoglobin?*
- Yes
- No
Have you ever experienced fainting after an injection or medical procedure?*
- Yes
- No
Have you ever been bothered by a tight band on the underside of your penis that causes pain or bleeding during sex?*
- Yes
- No
If yes, please describe:
Please list any medications you are taking.*
(name/dosage)
Appointment
Do you already have your appointment booked?*
- Yes (Thanks for completing registration.)
- No (Great. We will call you to schedule the procedure.)
Circumcision Consent
You must consent to the following:
*
- I have carefully considered the risks and benefits of this procedure and have discussed them with our family physician or other healthcare professional prior to coming to Gentle Procedures Clinic.
*
- I understand that Gentle Procedures is one of the few clinics offering circumcision on adults under local anaesthesia and they have explained to me this new approach.
*
- I understand that complications after circumcision can occur, although the frequency varies with skill and experience of the doctor, and are infrequent at Gentle Procedures. 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)
  - Infection requiring antibiotics (1/1000)
  - Sub-optimal cosmetic outcome (1/500)
  - Meatal stenosis or narrowing of the urethra (1/1000)
  - Trauma to the head of the penis (never in this practice)
  - Injury to the urethra including urethra-cutaneous fistula (1/1000)
  - Pain during and after sex post op (1/1,000)
  - Tightness or painful scar at the incision site post op, which may be long-term (1/500)
  - Change or loss of sensation to the penis (1/1,000)
  - More serious complications including death (never in this practice)
*
- I understand that it may be necessary for the doctor to use some or all of the following modalities to stop any bleeding should it occur:
  - Pressure dressings
  - Skin glue
  - Bipolar cautery
  - Suturing
*
- I know I must not take aspirin, anticoagulants (warfarin), or anti-inflammatories (NSAIDs) such as ibuprofen, naproxen, diclofenac, etc, 7 days before the procedure and for 2 days after.
Signature
Name
This field is for validation purposes and should be left unchanged.

Patient Information

Allergies

Medical History

Appointment

Circumcision Consent

Gentle Procedures

Services

Appointments