Adult Circumcision Registration

Patient Information
Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Healthcare Card Number
Address*
Street Address Address Line 2 City Province Postal Code
Preferred Phone*
Email*
Emergency Contact Name*
First Last
Emergency Contact Phone*
Where did you hear about us?*
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
If yes to any of the above, please describe:
Have you ever experienced fainting after an injection or medical procedure?*
- Yes
- No
Have you ever been bothered by a tight band on the underside of your penis that causes pain or bleeding during sex?*
- Yes
- No
Please list any medications you are taking:*
Referral Contacts - Optional
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 Gentle Procedures Clinic.
*
- I understand that Gentle Procedures 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 Gentle Procedures. Complications may include:
  - Significant post-op bleeding (1/400)
  - 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 (1/40,000)
  - Injury to the urethra including urethra-cutaneous fistula (1/1000)
  - Pain during and after sex post-op (1/1,000)
  - Tightness or painful scar at the incision site post op, which may be long-term (1/500)
  - Change or loss of sensation to the penis (1/1,000)
  - More serious complications including death (1/1,000,000)
*
- 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 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 a late cancellation or no-show will result in the loss of the deposit.
Phone
This field is for validation purposes and should be left unchanged.

Adult Circumcision

Adult Circumcision Intake Form

Patient Information

Medical History

Referral Contacts - Optional

Circumcision Consent