Registration for Circumcision

Baby Information
Baby's Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Healthcare Card Number, if available
Parent Information
Mother's Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Healthcare Card Number, if available
Father's 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*
How did you hear about us?*
- Online / Google
- Paediatrician / Doctor's Referral
- Friend / Family Member
- Radio
Medical History
Has the baby had any medical or bleeding problems, or blood loss, since birth?*
- Yes
- No
Does your family have any history of bleeding problems?*
- Yes
- No
If yes, describe:
Were there any significant problems for baby or mother during delivery?*
- Yes
- No
If yes, describe:
Medications
Please list any medications your son is taking (name/dosage):*
Type n/a if none
Contact Information
Please complete all relevant details.
Family Physician / Pediatrician Name
First Last
Phone
City
City
Referring Physician
First Last
Phone
City
City
Obstetrician or Delivery Doctor
First Last
Phone
City
City
Doulah / Midwife
First Last
Phone
City
City
Prenatal Instructor
First Last
Phone
City
City
List any health care professionals not included above.
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 prior to seeing Dr.Lohlun.
*
- We understand that we are making a consent by proxy for our infant 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 the 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 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 including urethra-cutaneous fistula (1/1,000)
  - More serious complications including death (1/1,000,000)
*
- We understand that we must not give our son any anti-inflammatory medications in the 7 days before his procedure. Examples: ADVIL, IBUPROFEN, ASPIRIN, MOTRIN, etc.
*
- We understand that a late cancellation or no-show will result in the loss of the deposit.
Email
This field is for validation purposes and should be left unchanged.

Baby Circumcision Registration

Baby Circumcision Registration Form

Baby Information

Parent Information

Medical History

Medications

Contact Information

Circumcision Consent