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.

"*" indicates required fields

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

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?*

Appointment

Do you already have your appointment booked?*

Circumcision Consent

You must consent to the following:
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Electronic Consent Form

By providing your contact information and engaging with Dr. Kanu, you consent to receive communications related to your healthcare and treatment through electronic means. This may include, but is not limited to, emails, text messages, appointment reminders, prescription updates, and ither notifications related to your medical care.

You have the right to withdraw consent to receive electronic communications at any time by notifying Dr. Kanu or Gentle Procedures at 289-389-3748 or info@gentleprocedureshamilton.ca. Please note that withdrawing consent may impact the timeliness and effectiveness of communication related to your care.

By consenting to electronic communication, you authorize that we have your authorization to receive, read, and store electronic messages related to your care.
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