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Circumcision Clinic Hamilton, Ontario

Circumcision
Penile Frenulectomy
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Circumcision
Penile Frenulectomy
Contact
About

Baby Circumcision Registration

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.

Baby Information
Baby's Name*
First Last
Date of Birth*
DD dash MM dash YYYY
Healthcare Card Number
Parent Information
First Parent's Name*
First Last
Second Parent's Name*
First Last
Address*
Address line 1 Address line 2 Town or City Province Postal Code
Preferred Phone*
Email*
Family Doctor / Pediatrician
First Name Last Name
Family Doctor's Phone Number
Family Doctor/Pediatrician's Medical Centre or Workplace
How did you hear about us?*
- Online / Google
- Paediatrician / Doctor's Referral
- Friend or Family Member
- Radio
Preferred clinic location
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?*
- Yes
- No
If yes, please describe:
Were there any significant 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):*
If breastfeeding, please list any medications you are taking (name/dosage):*
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?*
- Yes
- No
Appointment
Do you already have your appointment booked?*
- Yes (Thanks for completing registration.)
- No (Great. We will call you to schedule the procedure.)
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 if one parent is not present, we must still show written consent from that parent acknowledging that there is agreement from both parents to proceed with the procedure.
*
- 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 understand that our son must not have any anti-inflammatory medications in the 7 days prior to his procedure. Examples: ADVIL, IBUPROFEN, ASPIRIN, MOTRIN, etc.
*
- 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)
First Parent's Signature
Second Parent's Signature
Email
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

96 Niagara Street
St. Catharines, ON L2R 4L4

Fax: 905-393-3748

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