Call Us to Book : 204-697-9013
Buenafe Clinic, Winnipeg, Manitoba
COVID-19 Info

Search

Close

Erectile Dysfunction Doctor in Winnipeg, Manitoba

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
  
  Request Appointment
About
- Buenafe Clinic
- Location
- Blog
- Media
Contact

Men’s Sexual Health
No-Scalpel Vasectomy
Circumcision
Contact
About
- Buenafe Clinic
- Location
- Blog
- Media

Men’s Sexual Health
No-Scalpel Vasectomy
Circumcision
Contact
About
- Buenafe Clinic
- Location
- Blog
- Media

Menu

Men’s Sexual Health
No-Scalpel Vasectomy
Circumcision
Contact
About
- Buenafe Clinic
- Location
- Blog
- Media

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
Baby's Name*
First Last
Date of Birth*
MM slash DD slash YYYY
MHSC Number
PHIN Number
Parent Information
First Parent's Name*
First Last
First Parent's MHSC Number
First Parent's PHIN Number
Second Parent's Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Preferred Phone*
Email*
How did you hear about us?*
- Online / Google
- Paediatrician / Doctor's Referral
- Friend / Family Member
- Radio
Medical History
Has your baby had any medical or bleeding problems, or blood loss, since birth? Does your family have any history of bleeding problems? Do you have any reason to believe that your son has low blood or low hemoglobin?*
- Yes
- No
If yes, please describe:
Were there any significant problems for the child or mother when the child was born?*
- Yes
- No
If yes, please describe:
Please list any medications your son is taking (name/dosage):*
Type n/a if none
If breastfeeding, please list any medications you are taking (name/dosage):*
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.
Family Physician / Pediatrician Name
First Last
Phone
City
City
Referring Healthcare Professional Name
First Last
Phone
City
City
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.
*
- We understand that we are making a consent by proxy for our son 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 that parents 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 the 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)
  - Buried or trapped penis in the abdomen (1/800)
  - Infection requiring antibiotics (1/1000)
  - Meatal stenosis or narrowing of the urethra (1/1000)
  - Sub-optimal cosmetic outcome (1/500)
  - Trauma to the head of the penis (never in this practice)
  - More serious complications including death (never in this practice)
*
- We understand that our son must not have any anti-inflammatory medications in the 7 days prior to his procedure. Examples: ADVIL, IBUPROFEN, ASPIRIN, MOTRIN, etc.
*
- We agree to have our son circumcised by Dr. Buenafe. By submitting this consent form we are acknowledging that the complications and risks of this procedure have been explained to us.
*
- We understand that once an appointment is scheduled we can change/cancel with 48 hours notice and that cancellations less than 48 hours in advance incur a $150 fee.
First Parent's Signature
Second Parent's 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

Our Clinic
Location
Blog
Media

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
Take the ED Quiz

©Buenafe Clinic | All Rights Reserved | Site Map | Privacy Policy | Terms
Website by Lifter