Circumcision Clinic Hamilton, Ontario
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Penile Frenulectomy Registration

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Please complete the registration form below for penile frenulectomy or frenuloplasty.

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

Thanks for booking with us.

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Patient Information

Name*
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Address*
Reason for consultation*
Emergency Contact Name*
Family Doctor
How did you hear about us?*

Reasons you are seeking a frenulectomy (select all that apply):*

Allergies

Do you have any allergies?*

Medical History

Do you have a history of easy bruising?*
Do you have nosebleeds with little or no trauma?*
Have you ever had abnormal or prolonged bleeding after a dental procedure?*
Did you have 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 you have low blood pressure or low hemoglobin?*
Have you ever experienced fainting after an injection or medical procedure?*
(name/dosage)

Measles Screening

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