Circumcision Clinic Hamilton, Ontario
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Boy and Teen Circumcision Registration

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Please complete the registration form below for circumcision for boys aged 2 to 17 years.

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

Thanks for booking with us.

"*" indicates required fields

Child Information

Child's Name*
DD slash MM slash YYYY

Parent Information

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

Medical History

Has your son 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?*
Enter "none" if none

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?*
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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