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Child Circumcision Registration (00 – 14 years of age)
2022-02-21T09:40:49+09:00
Child Circumcision Registration (00 - 14 years of age)
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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).
COVID-19 Questionnaire (Parent to complete)
Has your child had fever or temperature in the past 14 days
*
Yes
No
Has your child had a cough in the past 14 days
*
Yes
No
Has your child 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
Child's Name
*
First
Last
Child's Date of Birth
*
Day
Month
Year
Home Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Child's Medicare Card Number
*
If you have not received your Medicare card for your child, please enter parents Medicare card number and reference number in child as 0.
Child's Medicare Card Reference Number
*
Expiry Date mm/yyyy
*
Parent A's (example Mother) Ref Number
*
Parent B's (example Father) Ref Number
*
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
Parent / Legal Guardian Details:
PARENT A (example Mother)
*
First
Last
Parent A's Date of Birth
*
Day
Month
Year
Parent A's Email
*
Parent A's Phone
*
PARENT B (example Father)
*
First
Last
Parent B's Date of Birth
*
Day
Month
Year
Parent B's Email
*
Parent B's Phone
*
Are there court orders in place for your child?
*
Yes
No
If YES, a copy is required to be reviewed by the doctor before the procedure is performed.
Please upload a copy of the court order in PDF format
Drop files here or
Select files
Accepted file types: pdf, Max. file size: 64 MB.
Please note, the only accepted format is PDF
How did you hear about us?
*
Online / Google
GP / Doctor's Referral
Friend or Family Member
Facebook
General Doctor Details / Obstetrician Details If child <6 months
Your Family GP Clinic
First
Last
Do you have a doctor (GP) that your son visits? If so please provide their details and we will send them a letter stating the procedure performed.
Practice Name
Practice Phone
Practice Address
Street Address
or Suburb
State / Province / Region
ZIP / Postal Code
Obstetrician Name (If your child is under 6 months of age)
First
Last
Obstetrician Phone
Hospital where the child was born
Has your son had the Vitamin K Injection at birth?
*
Yes
No
Medical History (Tick if appropriate)
Has your child had any medical or bleeding problems, or blood loss, since birth? (If yes, details)
*
Yes
No
Please describe
Does your family have any history of bleeding problems? (if yes, details)
*
Yes
No
Please describe:
Do you have any reason to believe that your child has low blood or low hemoglobin?
*
Yes
No
Were there any significant problems for the child or mother when the child was born?
*
Yes
No
Please describe:
Does your child have any allergies?
*
Yes
No
Please list any medications your son is taking (name/dosage), this is to include supplements (example: Vitamin C):
*
Type n/a if none
If breastfeeding, please list any medications you are taking (name/dosage)
*
Type n/a if none. Example medications include (Warfarin, Xarelto). If you are taking any medication please list and you will need to call 1300 755 055 as blood thinners thin the blood.
Has your son been diagnosed with a blood born disease?
*
Yes
No
Are you breast feeding?
*
Yes
No
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 stock Xylocaine 2% Jelly please do not purchase an alternative.
Will you / Did you apply numbing cream (Xylocaine 2 % jelly) at home before the 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.
Where will you / did you apply it?
*
* Please apply the numbing cream on the head of the penis and the base of the penis.
How much will you / did you use?
*
* We suggest using a small amount, about the size of a 20 cent piece.
Pain Management
Although we use effective local anaesthetic and additionally for some patients sedation and Penthrox (3+ years of age), we cannot guarantee a painless procedure and some patients do experience break through pain.
*
Yes, I understand my child may experience break through pain.
Weight
For Infants & Babies - you MUST get your son weighed 2 -3 days before his appointment & call our office with the details - 07 2103 2322. Your child's weight determines how long we wait in between each stage and how much local anaesthetic we can safely use. The treating doctor will perform a nerve block by injecting either side of the penis into the subcutaneous tissues and at the base of the penis. Risk of local anaesthetic: fitting, coma, respiratory depression, cardiac arrythmias and death.
Have you weighed your son?
*
Yes - I have had my son weighed 2 - 3 days before appointment
No - I have not had my son weighed 2 - 3 days before appointment
How much does your child weigh?
*
Kg
Date weight was taken?
*
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.
Please enter a note and this will be brought to the treating doctors attention at your appointment.
*
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 are aware that the use of local anaesthetic will be administered. Risks of local anaesthetic: fitting, coma, respiratory depression, cardiac arrythmias and death.
*
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 setting 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 complications may include
Please note it is our responsibility to ensure you are aware that there are potential complications with any medical procedure, including a Circumcision. You must understand these before your son's procedure is performed. If there is anything you do not understand please add to the questions section.
Please enter a note and this will be brought to the treating doctors attention at your appointment.
*
Significant post operative bleeding (1/400)
*
Trauma to the head of the penis (1/40,000)
*
Infection requiring antibiotics (1/1,000)
*
Change of the loss of sensation to the penis (1/1000)
*
Buried or trapped penis in the abdomen (1/800)
*
Meatal stenosis / narrowing of the urethra (1/1,000)
*
Injury to Urethra or Urethro Cutenous Fistula (1/1000)
*
Sub-optimal cosmetic outcome (1/500)
*
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)
*
Risk of local anaesthetic – fitting, coma, respiratory depression, cardiac arrythmias and death. (very low risk)
*
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.
Technique Used at Gentle Procedures Clinic Queensland:
The Pollock Technique™ uses a Mogen clamp. After much research, we find this approach is less invasive, there is less handling of the tissue. It is also 10 x faster than traditional circumcisions. The shorter the duration of any surgical procedure, the easier the recovery.
*
Yes, we are aware that Gentle Procedures Clinic Queensland performs all circumcisions via the "Pollock technique" We do not do the Plastibell technique.
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.
*
If you answer NO to this question we will be unable to provide you with things such as a medical certificate or a letter to your GP.
Yes
No
Sending SMS reminders for appointment using the number provided.
*
If you answer NO to this you will not receive appointment SMS messages.
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 child's medical file and are secure.
*
Yes
No
Disclosure and sending of photos to a specialist or other healthcare providers if medically indicated.
*
Yes
No
Are both parent/guardians attending?
*
Yes
No
Parent Details
Parent A'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.
Parent A's Full Name
*
First
Last
Date Signed (Parent A)
*
Day
Month
Year
Parent B'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.
Parent B's Full Name
*
First
Last
Date Signed (Parent B)
*
Day
Month
Year
The date you have digitally signed this document.
Phone
This field is for validation purposes and should be left unchanged.
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