Baby Circumcision Registration

Child Information
Baby's Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
MHSC Number
PHIN Number
Parent Information
Mother's Name*
First Last
Mother's MHSC Number
Mother's PHIN Number
Father's Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Preferred Phone*
Email*
How did you first become aware of us?
- Online search
- Doctor referral
- Referral by family/friend
- Print advertising
- Radio
- Social media (Facebook etc.)
- Other
If "other" source please specify:
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 $100 fee.
Comments
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Infant Circumcision Registration

Infant Circumcision Registration Form

Child Information

Parent Information

Medical History

Referral Contacts - Optional

Circumcision Consent