Baby Circumcision Registration (00 - 1 years of age) - PREVIEW - Gentle Procedures Circumcision & Vasectomy Clinics - Dr David Hunt

Circumcision Consent

You must consent to all tick boxes, if there are things you do not consent to, this will need to be discussed with the doctor prior to your appointment. (you may be called)

*

We have carefully considered the risks and benefits of this procedure and have discussed them with our family physician or other healthcare professional prior to seeing Dr David Hunt.

*

We understand that we are making a consent by proxy for our child for a non-therapeutic procedure. By signing this form, we have given our consent to this procedure as the parents of this child.

*

If one parent is not present on the day of the procedure we must still show written consent from the parent who could not attend, acknowledging consent from both parents to proceed with the procedure.

*

Complications after circumcision can occur, although the frequency varies with skill and experience of the doctor, and are infrequent in our practice.

*

We 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 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 of the loss of sensation to the penis (1/1000)

*

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 / 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

Disclosure and sending of photos to a specialist or other healthcare providers if medically indicated.*

Yes
No

Leaving a voicemail disclosing the caller ID.*

Yes
No

Debt management agency if required (if account has not been paid).*

Yes
No

If medically indicated you may be asked to send photos during the healing phase. All photos are stored in your child's medical file and are secure.*

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.

Mother's 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.

Mother's Full Name*

First Last

Date Signed (Mother)*

DD

MM

YYYY

Father's 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.

Father's Full Name*

First Last

Date Signed (Father)*

DD

MM

YYYY

The date you have digitally signed this document.

Name

This field is for validation purposes and should be left unchanged.

Baby Circumcision Registration (00-1 years of age) - 2020

Step 1 of 4

COVID-19 Questionnaire (Parent to complete)

Patient Information

Parent / Legal Guardian Details:

General Doctor Details / Obstetrician Details If child <6 months

Medical History (Tick if appropriate)

Application of numbing cream at home before appointment

Child's Weight

Circumcision Consent

Circumcision complications may include

Circumcision consent / privacy / release of information:

Baby Circumcision Registration (00 – 1 years of age) – PREVIEW

Baby Circumcision Registration (00-1 years of age) - 2020

Step 1 of 4

COVID-19 Questionnaire (Parent to complete)

Patient Information

Parent / Legal Guardian Details:

General Doctor Details / Obstetrician Details If child <6 months

Medical History (Tick if appropriate)

Application of numbing cream at home before appointment

Child's Weight

Circumcision Consent

Circumcision complications may include

Circumcision consent / privacy / release of information: