Adult Circumcision Registration

Patient Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Healthcare Card Number, if available
Address*
Street Address Address Line 2 City Province Postal Code
Preferred 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
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
If yes to any of the above, describe:
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 you haven’t previously had a vasectomy, have you ever considered having one?*
- Yes
- No
Medications
Please list any medications you are taking:
(name/dosage)
Contact Information
Please complete all relevant details.
Family Physician
First Last
Phone
Address
City
Referring Physician
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 my family physician or other healthcare professional prior to seeing Dr. Lohlun.
*
- I understand that Dr Lohlun is one of the few doctors offering circumcision on adults under local anesthesia. Dr. Lohlun has explained to me that this is a new approach.
*
- I understand that complications after circumcision can occur, although the frequency varies with skill and experience of the doctor, and are infrequent in Dr. Lohlun’s practice. 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 (1/1,000)
  - Meatal stenosis or narrowing of the urethra (1/1,000)
  - Sub-optimal cosmetic outcome (1/500)
  - Trauma to the head of the penis (1/40,000)
  - Injury to the urethra – Urethro Cutenous Fistula (1/1,000)
  - More serious complications including death (1/1,000,000)
  - Pain during and after sex post op (1/1,000)
  - Tightness or painful scar at the incision site post op, which may be long-term (1/500)
  - Change or loss of sensation to the penis (1/1,000)
*
- 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
*
- Dr. Lohlun has explained that, in his opinion, circumcision would definitely be beneficial to me. However, he believes that it does not qualify for being classified as medically necessary, according to Alberta Health requirements and therefore does not meet guidelines to bill Alberta Health for non-medically necessary service. I request to pay privately for this procedure as per Dr. Lohlun’s private fee schedule.
*
- I agree that I will not take any anti-inflammatory medications in the 7 days before my procedure Examples: ADVIL, IBUPROFEN, ASPIRIN, MOTRIN, etc.
*
- I understand that a late cancellation or no-show will result in the loss of the deposit.
Comments
This field is for validation purposes and should be left unchanged.

Adult Circumcision Registration

Adult Circumcision Registration Form

Patient Information

Medical History

Medications

Contact Information

Circumcision Consent