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- Gold Coast | Underwood |Bowen Hills | Burpengary East | Toowoomba. Circumcision & Vasectomy Clinic. OPEN SATURDAY'S |
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Vasectomy
Our Clinic
No-Scalpel Procedure
Before Vasectomy
After Vasectomy
Request Appointment
Vasectomy Fees
Vasectomy Registration
Patient Manual Download
No-Scalpel Vasectomy Video
Circumcision
Our Clinic
Baby Circumcision
Adult Circumcision
Teen Circumcision
Appointment Request
Circumcision Fees
Post Circumcision Care
Parent Counselling Video
The Pollock Technique™
Registration
Patient Manual Downloads
Penile Frenulectomy
Penile Frenulectomy
Appointment Request
Confirm Costs
Contact
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Adult Circumcision Registration (15+ age) – Preview Page
Adult Circumcision Registration (15+ age) – Preview Page
Gentle Procedures
2020-04-22T20:51:55+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
*
DD
MM
YYYY
Medicare Card Number
*
Medicare Reference Number
*
Medicare Expiration Date mm/yyyy
*
Department of Veteran Affairs (If applicable)
DVA Card Expiry Date
DD
MM
YYYY
DVA Card Colour
White
Orange
Gold
Healthcare Card Number (if applicable)
Healthcare Card Expiry Date
DD
MM
YYYY
Healthcare Card Type
New start
Disability
Pensioner Card Number (if applicable)
Pensioner Card Expiry Date
DD
MM
YYYY
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)
Application of Numbing Cream at Home Before Appointment
Did you apply numbing cream at home before your appointment:
*
Yes
No
Did you use: Numit or Xylocaine 2% jelly please tick
*
Numit
Xylocaine 2%
What time did you apply it
*
:
HH
MM
AM
PM
How much did you use?
*
Where did you apply it?
*
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 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 leave unticked and this will be discussed on the day of 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)
*
More serious complications including death (1/1,000,000)
*
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 (1/1,000)
*
Meatal stenosis / narrowing of the urethra (1/1,000)
*
Injury to Urethra or Urethro Cutenous Fistula (1/1000)
*
Change or loss of sensation to the penis (1/1,000)
*
Sub-optimal cosmetic outcome (1/500)
*
Tightness or painful scar at the incision site post operatively, which may be long-term (1/500)
Circumcision Consent
You must consent to the following:
*
I have carefully considered the risks and benefits of this procedure and have discussed them with my family physician or other healthcare professional prior to seeing Dr David Hunt.
*
Complications after circumcision can occur, although the frequency varies with skill and experience of the doctor, and are infrequent in our practice.
*
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 / privacy / release of information:
In accordance with the Privacy Act (1988), all information collected by Gentle Procedures Clinic Queensland is treated as confidential. To protect your privacy Gentle Procedures Clinic Queensland operates in accordance with this act. (Please tick the items listed to indicate your consent to disclose the following items).
Sending SMS appointment reminders and sending SMS for patient recalls.
*
Yes
No
Leaving a voicemail disclosing the caller ID.
*
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
Debt management agency if required (if account has not been paid).
*
Yes
No
Medical defence / Legal matter
*
Yes
No
Please note this only relates if a medical defence case was brought against Gentle Procedures Clinic Queensland. The likely hood of this is extremely low.
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.
DD
MM
YYYY
Name
This field is for validation purposes and should be left unchanged.
