Single Parent 00 – 14 Years of Age
Child Circumcision Registration & Consent Form

 

  • When submitting this form it will be encrypted and automatically transmitted to our office, we then add the form to your son’s medical chart. By completing and signing the form electronically you  are making an informed decision and consent to the procedure being performed.
  • If you do not consent to some or all of the sections in this form do not submit the form and contact our office to discuss – 07 2103 2322.
  • Most fields are mandatory, if you do not have the answer please enter n/a for not applicable.
  • If you do not have your son on your Medicare card at the time of registration please enter a parents Medicare card number, reference and expiry date.
  • All information provided by you is confidential and will be handled in accordance with our Privacy Policy.
  • If you have a question or comment regarding the consent; complications; privacy or release of information sections, please enter the details of your enquiry or concerns in each note section.
    • You are required to bring your son’s birth certificate to the appointment and upload it when completing the online form.