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.
Comments
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Adult Circumcision

Adult Circumcision Intake Form

Patient Information

Medical History

Referral Contacts - Optional

Circumcision Consent