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Buenafe Clinic, Winnipeg, Manitoba
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Vasectomy
No-Scalpel Vasectomy
Our Vasectomy Clinic
No-Scalpel Procedure
Before Vasectomy
After Vasectomy
Nitrous Oxide Vasectomy
Procedure Video
Download Guide
Take Action
Request Appointment
Vasectomy Fees
Registration
Book a Vasectomy
Circumcision
Circumcision for All Ages
Our Circumcision Clinic
Baby Circumcision
Adult Circumcision
Boy & Teen Circumcision
Our Method
Parent Counselling Video
Procedure Videos
Download Guide
Post Procedure Care
Take Action
Request Appointment
Circumcision Fees
Confirm Costs
Registration
Book A Circumcision
Men’s Sexual Health
Men's Sexual Health Program
Our Men's Health Clinic
Erectile Dysfunction
Peyronie’s Disease
Low Testosterone
Premature Ejaculation
Penis Enlargement
Delayed Ejaculation
Frenulum Breve
Download Guide
Treatments
Shockwave Therapy
Injection Therapy
Trimix Injection
Sex Therapy
Penile Frenulectomy
Learn More
Take Action
Book a Consultation
Erectile Dysfunction Quiz
Low Testosterone Quiz
Registration
Quick Contact
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About
Buenafe Clinic
Location
Blog
Media
Contact
Men’s Health Appointment
Vasectomy Appointment
Circumcision Appointment
Registration
Men’s Sexual Health
Men’s Sexual Health Clinic
Erectile Dysfunction
Peyronie’s Disease
Low Testosterone
Delayed Ejaculation
Frenulum Breve
Premature Ejaculation
Penis Enlargement
Frenulum Breve
Shockwave Therapy
Penile Injection Therapy
Trimix Injection
Penile Frenulectomy
Sex Therapy
Book a Consultation
Erectile Dysfunction Quiz
Take the Low T Quiz
Registration
No-Scalpel Vasectomy
Our Vasectomy Clinic
No-Scalpel Procedure
Before Vasectomy
After Vasectomy
Vasectomy Fees
Request Appointment
Nitrous Oxide Vasectomy
Download Guide
Vasectomy Registration
Procedure Video
Circumcision
Our Circumcision Clinic
Baby Circumcision
Adult Circumcision
Teen & Boy Circumcision
Request Appointment
Circumcision Fees
Our Method
Confirm Costs
Parent Counselling Video
Registration
Procedure Videos
Download Guide
Post Procedure Care
Contact
Contact Us
Men’s Health Appointment
Vasectomy Appointment
Circumcision Appointment
Registration
About
Buenafe Clinic
Location
Blog
Media
Men’s Sexual Health
Men’s Sexual Health Clinic
Erectile Dysfunction
Peyronie’s Disease
Low Testosterone
Delayed Ejaculation
Frenulum Breve
Premature Ejaculation
Penis Enlargement
Frenulum Breve
Shockwave Therapy
Penile Injection Therapy
Trimix Injection
Penile Frenulectomy
Sex Therapy
Book a Consultation
Erectile Dysfunction Quiz
Take the Low T Quiz
Registration
No-Scalpel Vasectomy
Our Vasectomy Clinic
No-Scalpel Procedure
Before Vasectomy
After Vasectomy
Vasectomy Fees
Request Appointment
Nitrous Oxide Vasectomy
Download Guide
Vasectomy Registration
Procedure Video
Circumcision
Our Circumcision Clinic
Baby Circumcision
Adult Circumcision
Teen & Boy Circumcision
Request Appointment
Circumcision Fees
Our Method
Confirm Costs
Parent Counselling Video
Registration
Procedure Videos
Download Guide
Post Procedure Care
Contact
Contact Us
Men’s Health Appointment
Vasectomy Appointment
Circumcision Appointment
Registration
About
Buenafe Clinic
Location
Blog
Media
Menu
Men’s Sexual Health
Men’s Sexual Health Clinic
Erectile Dysfunction
Peyronie’s Disease
Low Testosterone
Delayed Ejaculation
Frenulum Breve
Premature Ejaculation
Penis Enlargement
Frenulum Breve
Shockwave Therapy
Penile Injection Therapy
Trimix Injection
Penile Frenulectomy
Sex Therapy
Book a Consultation
Erectile Dysfunction Quiz
Take the Low T Quiz
Registration
No-Scalpel Vasectomy
Our Vasectomy Clinic
No-Scalpel Procedure
Before Vasectomy
After Vasectomy
Vasectomy Fees
Request Appointment
Nitrous Oxide Vasectomy
Download Guide
Vasectomy Registration
Procedure Video
Circumcision
Our Circumcision Clinic
Baby Circumcision
Adult Circumcision
Teen & Boy Circumcision
Request Appointment
Circumcision Fees
Our Method
Confirm Costs
Parent Counselling Video
Registration
Procedure Videos
Download Guide
Post Procedure Care
Contact
Contact Us
Men’s Health Appointment
Vasectomy Appointment
Circumcision Appointment
Registration
About
Buenafe Clinic
Location
Blog
Media
Registration
Adult Circumcision Registration
Please complete the registration form below for adult circumcision. We will reply to confirm your appointment (if not already scheduled) and answer your questions. Thanks for booking with us.
Patient Information
Name*
*
First
Last
Date of Birth*
*
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
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
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
Have you ever experienced fainting after an injection or medical procedure?*
*
Yes
No
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 $150 fee.
Signature
Comments
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