Baby Circumcision Registration

Baby Information
Baby's Name*
First Last
Date of Birth*
DD slash MM slash YYYY

Please bring proof of birthdate on the day of procedure (i.e. Under 6 Card or passport).
Parent Information
First Parent's Name*
First Last
Second Parent's Name*
First Last
Address*
Address line 1 Address line 2 County Country
Preferred Phone*
Email*
First Language
Family Doctor / GP*
First Name Last Name
Family Doctor / GP Address*
Address line 1 Address line 2 County Eircode Country
Family Doctor / GP's Phone Number
How did you hear about us?*
- Online / Google
- Paediatrician / Doctor's Referral
- Friend or Family Member
- Radio
Medical History
Has your baby had any bleeding problems, or blood loss, since birth? Does your family have any history of bleeding problems? Do you have any reason to believe that your son has low blood or low hemoglobin?*
- Yes
- No
If yes, please describe:
Were there any significant medical problems for the child or mother when the child was born?*
- Yes
- No
If yes, please describe:
Please list any medications your son is taking (name/dosage):*
Type n/a if none
If breastfeeding, please list any medications you are taking (name/dosage):*
Type n/a if none. Please note that if the mother is taking any form of blood thinner (Dalteparin, ASA) you will need to call the office to speak with one of our doctors prior to your appointment.
Allergies
Does your son have any allergies?*
- Yes
- No
If yes, please describe:
Circumcision Consent
You must consent to the following:
*
- We have carefully considered the risks and benefits of this procedure and have discussed them with our family physician or other healthcare professional.
*
- We understand that the Royal College of Physicians of Ireland does not support routine infant circumcision.
*
- We understand that we are making a consent by proxy for our infant for a non-therapeutic procedure. By submitting this form, we give our consent to this procedure as parents of this child.
*
- We agree to have our son circumcised at Gentle Procedures Clinic. By completing this form, we have given our consent to this procedure as parents of this child.
*
- We understand that complications can occur, although the frequency varies with the skill and experience of the doctor, and are infrequent with the Pollock Technique™. Complications include:
  - Significant post-op bleeding (1/400)
  - 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 (1/1000)
  - Meatal stenosis or narrowing of the urethra (1/1000)
  - Sub-optimal cosmetic outcome (1/500)
  - Trauma to the head of the penis (never in this practice)
  - More serious complications including death (never in this practice)
*
- We understand that we must not give any anti-inflammatory medications to our son in the 7 days prior to circumcision. Examples: IBUPROFEN, ASPIRIN, etc.
*
- We understand that patient instructions will be provided in English and that if a translator is required to ensure effective communication it is up to the patient to bring a suitable person. If communication is not assured, patient safety could be at risk and it may not be possible to proceed with the surgery as scheduled, and the deposit will be forfeit.
Phone
This field is for validation purposes and should be left unchanged.

Baby Circumcision Registration

Baby Information

Parent Information

Medical History

Allergies

Circumcision Consent