Child Circumcision Registration (00 - 14 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 at your appointment.

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

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 at your appointment.

Please enter a note and this will be brought to the treating doctors attention at your appointment.

*

Significant post operative bleeding (1/400)

*

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

*

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 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.

*

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 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.

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.

Name

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

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

Child's Weight

Circumcision Consent

Circumcision complications may include

Technique Used at Gentle Procedures Clinic Queensland:

Circumcision consent / privacy / release of information:

Parent Details