NON ATTENDING PARENTAL CONSENT - Circumcision Brisbane

QUEENSLAND’S

Trusted Circumcision & Vasectomy Clinic

SMS ENQUIRIES 0409 632 693 OR PHONE 07 2103 2322

NON ATTENDING PARENTAL CONSENT REGISTRATION

For any parent that cannot attend the scheduled appointment are required to complete a non-attending parental consent form. If there are court orders in place, please bring them with you as the doctor needs to sight it. It is important to know details about your son’s medical history, as it forms part of vital records for treatment with Gentle Procedures Clinic. The information you provide is confidential and will be handled per our Privacy Policy.We kindly ask you to complete this form a minimum of 48 hours before your appointment, as the information is reviewed by Dr Hunt. By completing, signing & submitting the form, you are making an informed consent to the procedure being performed. If you do not consent to some or all of the sections, do not complete or submit the form and contact our office to discuss further 07 2103 2322

Please note most sections on this form require an entry if you do not have a numeric number enter 0. For a text field enter X

Non Attending Parental Consent - Child Circumcision

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This field is for validation purposes and should be left unchanged.
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.

All information provided is confidential and will be handled in accordance with our Privacy Policy. We appreciate your assistance and completing this as soon as possible. In accordance with the Privacy Act (1988), all information collected by Gentle Procedures Clinic Queensland is treated as confidential. To protect your child's privacy Gentle Procedures Clinic Queensland operates in accordance with this act.
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.
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.
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)
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.
Pain Management
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:*
- Circumcision
- Penile Frenulectomy
- Revision
- Consultation
Child's Name*
First Last
Child's Date of Birth*
Day
Month
Year
Aftercare Instructions
Would like to receive a copy of the aftercare instructions?*
- Yes
- No
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*
Prefix First Last
Current Form Completed*
Day
Month
Year
The date you have digitally signed this document.
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0409 632 693

Trusted Circumcision & Vasectomy Clinic

NON ATTENDING PARENTAL CONSENT REGISTRATION

Non Attending Parental Consent - Child Circumcision

COMPLICATIONS MAY INCLUDE:

Pain Management

Aftercare Instructions

Clinic Locations

Gentle Procedures Spring Hill

Gentle Procedures UNDERWOOD

Gentle Procedures TOOWOOMBA EAST

AFTERCARE SUPPORT (Text Preferred)

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