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Erectile Dysfunction Doctor in Winnipeg, Manitoba
Registration

Infant Circumcision Registration

Please complete the registration form below for infant circumcision (babies up to 25 weeks of age).

We will call you back to confirm your appointment and answer your questions.

Thanks for booking with us.

  • Child Information

  • MM slash DD slash YYYY

  • Parent Information

  • Medical History

  • Type n/a if none
  • Type n/a if none. Please note that if the mother is taking any form of blood thinner (Dalteparin, ASA) you will need to call the office to speak with one of our doctors prior to your appointment.

  • Referral Contacts - Optional

    Please complete only if applicable.

  • Circumcision Consent

    You must consent to the following:
  • 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

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