Child & Teen Circumcision Registration

Child Information
Child's Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Healthcare Card Number, if available
Parent Information
Mother's Name*
First Last
Healthcare Card Number, if available
Father's Name*
First Last
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
- GP / Doctor's Referral
- Friend / Family Member
- Radio
Medical History
Has the son had 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 your son has low blood or low hemoglobin?*
- Yes
- No
If yes to any of the above, describe:
Were there any significant problems for the child or mother when the child was born?*
- 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
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 healthcare 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 child 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 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 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)
  - 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)
*
- We understand that our son must not have 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.
Comments
This field is for validation purposes and should be left unchanged.

Boy and Teen Circumcision Registration

Child & Teen Circumcision Registration Form

Child Information

Parent Information

Medical History

Medications

Contact Information

Circumcision Consent