Penile Preputioplasty Registration

Patient Information
Name*
First Last
Date of Birth*
DD slash MM slash YYYY
Address*
Address line 1 Address line 2 County Country
Preferred Phone*
Email*
Family Doctor / GP*
First Name Last Name
Family Doctor / GP Address*
Address line 1 Address line 2 County Eircode Country
Family Doctor's Phone Number
How did you hear about us?*
- Online / Google
- GP / Doctor's Referral
- Friend or Family Member
- Radio
Allergies
Do you have any allergies?*
- Yes
- No
If yes, please describe:
Medical History
Do you have a history of easy bruising?*
- Yes
- No
Do you have nosebleeds with little or no trauma?*
- Yes
- No
Have you ever had abnormal or prolonged bleeding after a dental procedure?*
- Yes
- No
Did you have any bleeding problems, or blood loss, since birth?*
- Yes
- No
Does your family have any history of bleeding problems?*
- Yes
- No
Do you have any reason to believe that you have low blood pressure or low hemoglobin?*
- Yes
- No
Have you ever experienced fainting after an injection or medical procedure?*
- Yes
- No
Have you ever been bothered by a tight band on the underside of your penis that causes pain or bleeding during sex?*
- Yes
- No
Do you have any active medical conditions or significant past medical history?*
- Yes
- No
If yes, please describe:
Please list any medications you are taking. Enter "none" if none.*
(name/dosage)
Emergency Contact Name*
First Last
Emergency Contact Phone*
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Circumcision Consent
You must consent to the following:
Hidden
*
- 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 coming to Gentle Procedures Clinic.
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*
- I understand that Gentle Procedures is one of the few clinics offering circumcision on adults under local anaesthesia and they have explained to me this new approach.
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*
- I understand that complications after circumcision can occur, although the frequency varies with skill and experience of the doctor, and are infrequent at Gentle Procedures. Complications may include:
  - Significant post-op bleeding (1/100)
  - Phimosis or narrowing of the shaft-skin opening over the head of the penis (1/500)
  - Infection requiring antibiotics (1/1000)
  - Sub-optimal cosmetic outcome (1/500)
  - Meatal stenosis or narrowing of the urethra (1/1000)
  - Trauma to the head of the penis (never in this practice)
  - Injury to the urethra including urethra-cutaneous fistula (1/1000)
  - More serious complications including death (never in this practice)
Hidden
*
- I understand that it may be necessary for the doctor to use some or all of the following modalities to stop any bleeding should it occur:
  - Pressure dressings
  - Skin glue
  - Bipolar cautery
  - Suturing
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- I know I must not take aspirin, anticoagulants (warfarin), or anti-inflammatories (NSAIDs) such as ibuprofen, naproxen, diclofenac, etc, 7 days before the procedure and for 2 days after.
Comments
This field is for validation purposes and should be left unchanged.

Preputioplasty Registration

Preputioplasty Registration Form

Patient Information

Allergies

Medical History

Circumcision Consent