Dorsal Slit Registration
For all enquiries relating to a Circumcision please complete all fields below.
Dorsal Slit Registration
For all enquiries relating to a Circumcision please complete all fields below.
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Dorsal Slit Registration
- When submitting the form it will be encrypted and automatically transmitted to our office, we then add the form to your medical chart. By completing and signing the form electronically you are making an informed consent to the procedure being performed on the date of your appointment. If you do not consent to some or all of the sections do not submit the form and contact our office to discuss – 07 2103 2322.
- Please note most sections on this form require an entry, if you do not have the answer please enter n/a for not applicable. If you do not have your Medicare card please enter the number 0 in each cell
- 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.
- We kindly ask YOU complete the form and that you do not get a family member or friend to complete the registration form on your behalf.
Please complete all fields in order to be able to submit it. If you are attending for a consultation only regarding a Circumcision we still request this form is completed. For teenagers the form must be completed by the patient and not the parent.