Adult Circumcision Registration

Please complete the registration form below for adult circumcision.

We will call you back to confirm your appointment and answer your questions.

Thanks for booking with us.

"*" indicates required fields

Email

This field is for validation purposes and should be left unchanged.

Patient Information

Name*

First Last

Date of Birth*

Medicare Card Number

(if available)

Healthcare Card Number

(if available)

Address*

Residential Address Suburb City State Post Code

Phone*

Email*

Emergency Contact Name*

First Last

Emergency Contact Phone*

How did you hear about us?*

Online / Google

GP / Doctor's Referral

Friend / Family Member

Radio

Other

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), enter N/A if none

Allergies

Do you have any allergies?*

Yes

No

If yes, please describe.

Referral Contacts - Optional

Family Physician

First Last

Phone

Address

City

Referring Healthcare Professional

First Last

Phone

Address

City

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 anesthesia 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)
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 confirm that I understand that I must not take any anti-inflammatory medications in the 7 days before my procedure. Examples: ADVIL, IBUPROFEN, ASPIRIN, MOTRIN, etc.

Signature

Adult Circumcision Registration

Patient Information

Medical History

Allergies

Referral Contacts - Optional

Circumcision Consent

Gentle Procedures

Services

Appointments