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Buenafe Clinic, Winnipeg, Manitoba
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Erectile Dysfunction Doctor in Winnipeg, Manitoba

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Circumcision
- Circumcision for All Ages
  
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Men’s Sexual Health
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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 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
Email
This field is for validation purposes and should be left unchanged.

Erectile Dysfunction Doctor in Winnipeg, Manitoba

Call now: 204-697-9013 | CONTACT US

930 Jefferson Avenue, Suite 203
Winnipeg, MB, R2P 1W1

Fax: 204-697-9017

Buenafe Clinic

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Location
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Services

No-Scalpel No-Needle Vasectomy
Newborn & Baby Circumcision
Adult Circumcision
Teen & Child Circumcision
Erectile Dysfunction Treatment
Peyronie’s Disease Treatment
Premature Ejaculation Treatment
Delayed Ejaculation Treatment
Frenulum Breve
Penis Enlargement
Testosterone Deficiency

Take Action

Book a Circumcision Appointment
Book a Vasectomy Appointment
Book an ED Treatment Appointment
Confirm Circumcision Cost
Confirm Vasectomy Cost
Take the ADAM Test
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