Baby Circumcision Registration

Please complete the registration form below for baby circumcision.

We will reply to confirm your appointment (if not already scheduled) and answer your questions.

Thanks for booking with us.

Baby Information

Baby's Name*(Required)
DD slash MM slash YYYY

Parent Information

First Parent's Name*(Required)
Second Parent's Name*(Required)
Family Doctor / Pediatrician
How did you hear about us?*(Required)

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?*(Required)
Were there any significant problems for the child or mother when the child was born?*(Required)
If the mother is taking any form of blood thinner (Dalteparin, ASA) you will need to speak with our doctor prior to your appointment.


Does your son have any allergies?*(Required)


Do you already have your appointment booked?*(Required)

Circumcision Consent

You must consent to the following:
This field is for validation purposes and should be left unchanged.