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Non Attending Parental Consent
Non-Attending Parental Consent Form
00 – 14 Years of Age
You have indicated by completing this form you will not be present on the day of the procedure and you consent for the procedure to be carried out without your presence. You are confirming that you are a legal parent / guardian. If you do not consent to anything on this page do not complete the form and contact our office urgently - 07 2103 2322.
Child's First Name
Child's Last Name
I 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.
I understand that I am making a consent by proxy for our child for a non-therapeutic procedure. By signing this form, I consent to this procedure as the parent of this child.
I understand that complications after circumcision can occur, although the frequency varies with skill and experience of the doctor, and are infrequent in Dr David Hunt's practice.
I have considered the potential medical benefits of circumcision and request to proceed despite the associated risks with the procedure.
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.
COMPLICATIONS MAY INCLUDE:
Please note it is our responsibility to ensure you are aware that there are complications and risks with any medical procedure, you must understand these before the procedure is performed. If there is anything you do not understand please add to the questions section.
Significant post operative bleeding (1/400)
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)
Sub-optimal cosmetic outcome (1/500)
Change of the loss of sensation to the penis (1/1000)
Tightness or painful scar at the incision site post operatively, which may be long-term (1/500)
Risk of local anaesthetic – fitting, coma, respiratory depression, cardiac arrythmias and death (very low risk)
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.
Although we use effective local anaesthetic and additionally for some patients (3+ years of age) sedation and Penthrox, we cannot guarantee a painless procedure and your son may experience break through pain.
Yes, I understand my child may experience break through pain.
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:
Please Tick the Procedure Your Son is Having:
Child's Date of Birth
Would like to receive a copy of the aftercare instructions?
If yes please provide your email address
Non-Attending Parent'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.
Non-Attending Parent's Full Name
The date you have digitally signed this document.
This field is for validation purposes and should be left unchanged.
For Appointments & Enquiries Tel: 07 2103 2322 | Email: firstname.lastname@example.org
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