Boys Over Five Years Old & Teen Circumcision Registration

Please complete the registration form below for circumcision for boys aged 5 to 17 years.

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

Thanks for booking with us.

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Child Information

Child's Name*

First Last

Date of Birth*

Medicare Card Number (if available)

Healthcare Card Number (if available)

Parent Information

Mother's Name*

First Last

Mother's Medicare Card Number

Mother's Healthcare Card Number (if available)

Father's Name*

First Last

Father's Medicare Card Number

Father's Healthcare Card Number (if available)

Address*

Residential Address Suburb City State Post Code

Phone*

Email*

How did you hear about us?*

Online / Google

GP / Doctor's Referral

Friend / Family Member

Radio

Other

Medical History

Has your son 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).*

Type N/A if none.

Allergies

Does your son have any allergies?*

Yes

No

If yes, please describe:

Referral Contacts - Optional

Family Physician / Pediatrician

First Last

Phone

City

Referring Healthcare Professional

First Last

Phone

City

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 General Procedures Clinic offers circumcision on older children under local anesthesia and we were explained this approach.

We understand that we are making a consent by proxy for our son for a non-therapeutic procedure. By signing this form, we have given our consent to this procedure as parents of this child.

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 complications after circumcision can occur, although the frequency varies with the skill and experience of the doctor, and are infrequent at Gentle Procedures Clinic. 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)
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)
Injury to the urethra including urethra-cutaneous fistula (1/1000)
More serious complications including death (never in this practice)

We understand that our child is no longer in the newborn period and 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

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 it may be necessary to restrain our child.

Signature*

Boys Over Five Years Old & Teen Circumcision Registration

Child Information

Parent Information

Medical History

Allergies

Referral Contacts - Optional

Circumcision Consent

Gentle Procedures

Services

Appointments