Baby Circumcision Registration

Baby Information

Baby's Name*(Required)

First Last

Date of Birth*(Required)

Healthcare Card Number

Parent Information

First Parent's Name*(Required)

First Last

Second Parent's Name*(Required)

First Last

Address*(Required)

Address line 1 Address line 2 Town or City Province Postal Code

Preferred Phone*(Required)

Email*(Required)

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?*(Required)

Online / Google

Paediatrician / Doctor's Referral

Friend or Family Member

Radio

Other

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)

Yes

If yes, please describe:

Were there any significant problems for the child or mother when the child was born?*(Required)

Yes

If yes, please describe:

Please list any medications your son is taking (name/dosage):*(Required)

If breastfeeding, please list any medications you are taking (name/dosage):*(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.

Allergies

Does your son have any allergies?*(Required)

Yes

If yes, please describe :

Appointment

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

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

Phone

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