Baby Circumcision Registration

Baby Information
Baby's Name*
First Last
Date of Birth*
YYYY dash MM dash DD
Healthcare Card Number
Parent Information
First Parent's Name*
First Last
Second Parent's Name*
First Last
Address*
Address line 1 Address line 2 Town or City Province Postal Code
Preferred Phone*
Email*
Family Doctor / Pediatrician
First Name Last Name
Family Doctor's Phone Number
Family Doctor/Pediatrician's Medical Centre or Workplace
How did you hear about us?*
- Online / Google
- Paediatrician / Doctor's Referral
- Friend or 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):*
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 speak with our doctor prior to your appointment.
Allergies
Does your son have any allergies?*
- Yes
- No
If yes, please describe :
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:
*
- 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 if one parent is not present, we must still show written consent from that parent acknowledging that there is agreement from both parents to proceed with the procedure.
*
- 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 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 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)
First Parent's Signature
Second Parent's Signature
Comments
This field is for validation purposes and should be left unchanged.

Baby Information

Parent Information

Medical History

Allergies

Appointment

Circumcision Consent

Gentle Procedures

Services

Appointments