Circumcision Clinic Hamilton, Ontario
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Baby Circumcision Registration

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Please complete the registration form below for baby circumcision.

We will reply to confirm your appointment (if not already scheduled) and answer your questions.

Thanks for booking with us.

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Baby Information

Baby's Name*
DD dash MM dash YYYY

Parent Information

First Parent's Name*
Second Parent's Name*
Address*
Family Doctor / Pediatrician
How did you hear about us?*

Medical History

Has your baby had any medical or 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?*
Were there any significant problems for the child or mother when the child was born?*
If the mother is taking any form of blood thinner (Dalteparin, ASA) you will need to speak with our doctor prior to your appointment.

Allergies

Does your son have any allergies?*

Measles Screening

Does your son or anyone in the household currently have a rash?*
Has your son or anyone in the household developed a fever in the last 4 days?*
Does your son or anyone in the household have any of the following respiratory symptoms?*
Does your son or anyone in the household currently have a sore throat, conjunctivitis or watery eyes?*
Has your son or anyone in the household been in contact with someone who has tested positive for Measles in the last 21 days?*

Appointment

Do you already have your appointment booked?*

Circumcision Consent

You must consent to the following:
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Clear Signature
Clear Signature
This field is for validation purposes and should be left unchanged.
Hamilton Circumcision Centre

Call now: 289-389-3748 | CONTACT US

77 Hunter Street East
Hamilton, ON L8N 1M4

272 Oxford Street West
London, ON N6H 1S9

51 Benton Street
Kitchener, ON N2G 3H1

261 Martindale Rd Unit 6
St. Catharines, ON L2W 1A1

672 Brant Street, Suite 200
Burlington, ON L7R 2H3

Henry Medical Centre
195 Henry St, Unit 05
Brantford, ON N3S 5C9

Fax: 905-502-1426

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