QUEENSLAND'S

Trusted Circumcision & Vasectomy Clinic

SMS ENQUIRIES 0409 632 693

CIRCUMCISION ENQUIRY FORM

For any enquiry please complete this form, we will respond to your enquiry promptly.

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Please enter the details of the patient*
First Name Last Name
Patient's date of birth*
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Month
Year
Contact Details (Please provide the details of the person we are to contact)
Contact Phone Number*
Email Address*
Are you wanting to book a Circumcision NOW?*
- Yes
- No
If Yes, which location would you prefer to attend?
- Underwood, Gold Coast (available every Saturday)
- Toowoomba East (available every Friday)
- Spring Hill, Brisbane (available Monday, Tuesday, Wednesday afternoons)
Do you have any questions you would like us to email you with the answers, if yes please describe
By submitting this form, you agree to be contacted by phone, email or text and that any associated call may be recorded for quality and training purposes. The number we will call you from is 0409632693 or a Private Number. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.*
By submitting this form, you agree to be contacted by phone, email or text and that any associated call may be recorded for quality and training purposes. The number we will call you from is 0409632693 or a Private Number. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.
- Yes
- No
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0409 632 693

QUEENSLAND'S

Trusted Circumcision & Vasectomy Clinic

SMS ENQUIRIES 0409 632 693

CIRCUMCISION ENQUIRY FORM

Clinic Locations

Gentle Procedures Spring Hill

Gentle Procedures UNDERWOOD

Gentle Procedures TOOWOOMBA EAST

AFTERCARE SUPPORT (Text Preferred)

Phone:

FAX:

PATIENT REGISTRATION

ONLINE SERVICES

POLICIES & PROCEDURES