Adult Circumcision Registration

Patient Information
Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Healthcare Card Number
MHSC Number
PHIN Number
Age*
Weight
Allergies
- Yes
- No
If yes, please describe
Address*
Street Address Address Line 2 City Province Postal Code
Preferred Phone*
Email*
Emergency Contact Name*
First Last
Emergency Contact Phone*
How did you first become aware of us?*
- Online search
- Doctor referral
- Referral by family/friend
- Print advertising
- Radio
- Social media (Facebook etc.)
- Other (please specify below)
If "other" source please specify:
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
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 yes, please describe:
Medications
Please list any medications you are taking including name and dosage: (including Aspirin, Advil, other anti-inflammatories)*
Type "N/A" if none
Allergies
Please list your allergies*
Type "N/A" if none
Referral Contacts - Optional
Please complete only if applicable.
Family Physician
First Last
Phone
Address
City
Referring Healthcare Professional
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 our family physician or other healthcare professional prior to coming to Buenafe Clinic.
*
- I understand that Buenafe Clinic is one of the few clinics offering circumcision on adults under local anesthesia and they have explained to me this new approach.
*
- I understand that complications after circumcision can occur, although the frequency varies with skill and experience of the doctor, and are infrequent at Buenafe Clinic. Complications may include:
  - Significant post-op bleeding (1/100)
  - Phimosis or narrowing of the shaft-skin opening over the head of the penis (1/500)
  - Infection requiring antibiotics (1/1000)
  - Sub-optimal cosmetic outcome (1/500)
  - Meatal stenosis or narrowing of the urethra (1/1000)
  - 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)
*
- I agree to be circumcised by Dr. Buenafe. By submitting this consent form I am acknowledging that the complications and risks of this procedure have been explained to me.
*
- 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
*
- I confirm that I understand that I must not take any anti-inflammatory medications in the 7 days before my procedure. Examples: ADVIL, IBUPROFEN, ASPIRIN, MOTRIN, etc.
*
- I understand that once an appointment is scheduled I can change/cancel with 48 hours notice and that cancellations less than 48 hours in advance incur a $100 fee.
Comments
This field is for validation purposes and should be left unchanged.

Adult Circumcision Registration

Adult Circumcision Registration Form

Patient Information

Medical History

Medications

Allergies

Referral Contacts - Optional

Circumcision Consent