Registration for Circumcision

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

Baby Information

Baby's Name(Required)

Date of Birth(Required)

Healthcare Number or ULI(Required)

Parent Information

Mother's Name(Required)

First Last

Date of Birth(Required)

Healthcare Card Number, if available

Father's Name(Required)

First Last

Date of Birth(Required)

Healthcare Card Number, if available

Address(Required)

Street Address Address Line 2 City Province Postal Code

Preferred Phone(Required)

Email(Required)

How did you hear about us?(Required)

Online / Google

Paediatrician / Doctor's Referral

Friend / Family Member

Radio

Other

Medical History

Has the baby had any medical or bleeding problems, or blood loss, since birth?(Required)

Yes

Does your family have any history of bleeding problems?(Required)

Yes

If yes, describe:

Were there any significant problems for baby or mother during delivery?(Required)

Yes

If yes, describe:

Medications

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

Type n/a if none

Contact Information

Please complete all relevant details.

Family Physician / Pediatrician Name

First Last

Phone

City

Referring Physician

First Last

Phone

City

Obstetrician or Delivery Doctor

First Last

Phone

City

Doulah / Midwife

First Last

Phone

City

Prenatal Instructor

First Last

Phone

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.

Baby Circumcision Registration

Baby Information

Parent Information

Medical History

Medications

Contact Information

Circumcision Consent

Lohlun Clinic
Westgrove Professional Building
#222, 10230-142 Street
Edmonton, AB T5N 3Y6