Child Circumcision Registration (00 - 14 years of age) - PREVIEW - Gentle Procedures Circumcision & Vasectomy Clinics - Dr David Hunt

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.

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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.

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We are aware that the use of local anaesthetic will be administered. Risks of local anaesthetic: fitting, coma, respiratory depression, cardiac arrythmias and death.

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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.

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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.

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

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We have considered the potential medical benefits of circumcision and request to proceed despite the associated risks with the procedure.

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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.

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Significant post operative bleeding (1/400)

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Risk of local anaesthetic – fitting, coma, respiratory depression, cardiac arrythmias and death. (very low risk)

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Trauma to the head of the penis (1/40,000)

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More serious complications including death (1/1,000,000)

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Phimosis or narrowing of the shaft-skin opening over the head of the penis (1/500)

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Buried or trapped penis in the abdomen (1/800)

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Infection requiring antibiotics (1/1,000)

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Meatal stenosis / narrowing of the urethra (1/1,000)

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Injury to Urethra or Urethro Cutenous Fistula (1/1000)

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

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Sub-optimal cosmetic outcome (1/500)

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Tightness or painful scar at the incision site post operatively, which may be long-term (1/500)

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.

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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)*

DD

MM

YYYY

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)*

DD

MM

YYYY

The date you have digitally signed this document.

Phone

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

Child Circumcision Registration (00 - 14 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 (Xylocaine 2% Jelly) at home before appointment

** DO NOT PURCHASE NUMIT

Pain Management

Child's Weight

Circumcision Consent

Circumcision complications may include

Technique Used at Gentle Procedures Clinic Queensland:

Circumcision Consent / Privacy / Release of information:

Parent Details

Child Circumcision Registration (00 – 14 years of age) – PREVIEW

Child Circumcision Registration (00 - 14 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 (Xylocaine 2% Jelly) at home before appointment

** DO NOT PURCHASE NUMIT

Pain Management

Child's Weight

Circumcision Consent

Circumcision complications may include

Technique Used at Gentle Procedures Clinic Queensland:

Circumcision Consent / Privacy / Release of information:

Parent Details