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Adult Circumcision Registration (15+ age) – Preview Page
2022-02-21T09:39:44+09:00
Adult Circumcision Registration (15+ age) - 2020
Step
1
of
4
25%
COVID-19 Questionnaire (Patient to complete)
Have you had a fever or temperature in the past 14 days?
*
Yes
No
Have you had a cough in the past 14 days?
*
Yes
No
Have you been unwell with flu like symptoms in the past 14 days
*
Yes
No
Has anyone in your immediate family travelled oversees in the past 14 days.
*
Yes
No
If you answered YES our doctor will be in contact with you prior to your appointment to confirm if you can attend this appointment.
Patient Information
Name
*
First
Last
Date of Birth
*
Day
Month
Year
Medicare Card Number
*
Your medicare number should be 10 digits long
Medicare Reference Number
*
Medicare Expiration Date mm/yyyy
*
Department of Veteran Affairs (If applicable)
DVA Card Expiry Date
Day
Month
Year
DVA Card Colour
White
Orange
Gold
Healthcare Card Number (if applicable)
Healthcare Card Expiry Date
Day
Month
Year
Healthcare Card Type
New start
Disability
Pensioner Card Number (if applicable)
Pensioner Card Expiry Date
Day
Month
Year
Pensioner Card Type
Aged
Disability
Address
*
Residential Address
or suburb
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
State
Post Code
Preferred Phone
*
Email
*
Emergency Contact Name
*
First
Last
Emergency Contact Phone
*
How did you hear about us?
*
Online / Google
GP / Doctor's Referral
Friend or Family Member
Facebook
General Doctor Details
GP Name
Practice Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Practice Phone (include area code)
Allergies
Do you have any allergies?
*
Yes
No
If yes, please describe:
Medical History
Do you have a history of easy bruising? (If yes, details)
*
Yes
No
Please describe
Do you have nosebleeds with little or no trauma? (If yes, details)
*
Yes
No
Please describe
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
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 currently taking, this is to include supplements (example: Vitamin C)
(name/dosage)
Sexual Health Screening
Due to the nature of the medical procedure you are about to undergo it is vital we know your sexual health history. Have you been diagnosed with:
*
None
Human Immunodeficiency Virus (HIV)
Hepatitis B
Hepatitis C
Human Papillomavirus (HPV)
Genital Warts
Treating Doctor Details
Please advise of the Doctor Name and contact telephone number
When diagnosed?
Application of Numbing Cream (Xylocaine 2% Jelly) at Home Before Appointment
The most significant part of our pain management is the local anaesthetic injections. The use of numbing cream before injections helps to mitigate pain. The cream is effective in 5-10 minutes, however there may be additional benefit putting it on for up to one hour before the procedure. We recommend using Xylocaine 2 % Jelly, it is relatively safe to use and is sold over the counter at chemists. There have been reports of adverse events when used in high doses over large areas and in the mouth.
** Do not purchase Numit
If your pharmacy does not sell Xylocaine 2% Jelly do not purchase an alternative.
Will you / Did you apply numbing cream (Xylocaine 2% Jelly)at home before your appointment:
*
Yes
No
What time will you / did you apply it
*
:
Hours
Minutes
AM
PM
AM/PM
* Please apply the numbing cream 45 - 60 minutes before the procedure.
How much will you / did you use?
*
* We suggest using a small amount, about the size of a 20 cent piece.
Where did you apply it?
*
* Please apply the numbing cream on the head of the penis and around the base of the penis.
Weight
How much do you weigh
*
kg
What is your height
*
cm
Circumcision complications may include
Please note it is our responsibility to ensure you are aware that there are complications with any medical procedure, including a circumcision. You must understand this before the procedure is performed. If there is anything you do not understand please leave unticked and this will be discussed at your appointment. (The number in brackets is the risk level for that complication)
*
Significant post operative bleeding (1/400)
*
Trauma to the head of the penis (1/40,000)
*
Infection requiring antibiotics (1/1,000)
*
Sub-optimal cosmetic outcome (1/500)
*
Change or loss of sensation to the penis (1/1,000)
*
Buried or trapped penis in the abdomen (1/800)
*
Injury to Urethra or Urethro Cutenous Fistula (1/1000)
*
Meatal stenosis / narrowing of the urethra (1/1,000)
*
Phimosis or narrowing of the shaft-skin opening over the head of the penis (1/500)
*
Tightness or painful scar at the incision site post operatively, which may be long-term (1/500)
*
More serious complications including death (1/1,000,000)
Circumcision Complication Questions
If you have any questions or concerns with the above complication section please list your questions here and it will be discussed in your consultation.
Circumcision Consent
Please note it is our responsibility to ensure you are aware that there are complications and risks with any medical procedure, including a Circumcision. You must understand the risks before the procedure is performed. If there is anything you do not understand please add to the questions section.
Anaesthetic Complications
*
Although we use effective local anaesthetic and additionally for some patients sedation and Penthrox, we cannot guarantee a painless procedure and some patients do experience break through pain.
Procedure Complications
*
Complications after circumcision can occur, although the frequency varies with skill and experience of the doctor, and are infrequent in our practice.
Modalities to stop bleeding should it occur when procedure is being performed.
Yes
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 BANDAGE / SKIN GLUE / BIPOLAR CAUTERY / SUTURING.
*
I have considered the potential medical benefits of circumcision and request to proceed despite the associated risks with the procedure.
*
In the unlikely event that the patient needed to attend a hospital they may be at risk of catching COVID 19 in a hospital settling and there may not be adequate staff available to attend to them if the pandemic progresses.
Circumcision Consent Questions
If you have any questions or concerns with the above consent section please list your questions here and it will be discussed in your consultation.
Circumcision Consent / Privacy / Release of information:
In accordance with the Privacy Act (1988), all information collected by Gentle Procedures Brisbane is treated as confidential. To protect your privacy Gentle Procedures Brisbane operates in accordance with this act. We may use your information provided for any of the following:
Disclosure to others involved in your healthcare including referrals to other health practitioners.
*
Yes
No
Sending SMS reminders for appointment using the number provided.
*
If you answer NO to this you will not receive any appointment confirmation SMS as you have indicated no
Yes
No
Leaving voicemails identifying the caller using the phone number provided.
*
If you answer NO to this means Dr Hunt cannot attempt to contact you post operatively as you have indicated no.
Yes
No
Sending communication via email using the email address provided.
*
If you answer NO to this that means we cannot email you your receipt or aftercare instructions.
Yes
No
If medically indicated you may be asked to send photos during the healing phase. All photos are stored in your medical file and are secure.
*
Yes
No
Disclosure and sending of photos to a specialist or other healthcare providers if medically indicated.
*
Yes
No
Signature
*
Please use your mouse or finger to digitally sign and consent to all items in this questionnaire. Please ensure to sign within the box provided.
Full Name
*
First
Last
Date Signed
*
The date you have digitally signed this document.
Day
Month
Year
Email
This field is for validation purposes and should be left unchanged.
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