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Circumcision Clinic Hamilton, Ontario

Circumcision
Penile Frenulectomy
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Circumcision
Penile Frenulectomy
Contact
About

Penile Frenulectomy Registration

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.

Patient Information
Name*
First Last
Date of Birth*
Date Format: DD slash MM slash YYYY
Address*
Street Address Address Line 2 City Province Postal Code
Preferred Phone*
Email*
Emergency Contact Name*
First Last
Emergency Contact Phone*
Family Doctor
First Name Last Name
Family Doctor's Phone Number
Family Doctor's Medical Centre or Workplace
How did you hear about us?*
- Online / Google
- GP / Doctor's Referral
- Friend or Family Member
- Radio
Reasons you are seeking a frenulectomy (select all that apply):*
- Discomfort and bleeding
- Premature ejaculation
Allergies
Do you have any allergies?*
- Yes
- No
If yes, please describe:
Medical History
Do you have a history of easy bruising?*
- Yes
- No
Do you have nosebleeds with little or no trauma?*
- Yes
- No
Have you ever had abnormal or prolonged bleeding after a dental procedure?*
- Yes
- No
Did you have any medical or bleeding problems, or blood loss, since birth?*
- Yes
- No
Does your family have any history of bleeding problems?*
- Yes
- No
Do you have any reason to believe that you have low blood pressure or low hemoglobin?*
- Yes
- No
Have you ever experienced fainting after an injection or medical procedure?*
- Yes
- No
If yes, please describe:
Please list any medications you are taking. Enter "none" if none.*
(name/dosage)
Consent
You must consent to the following:
*
- I have carefully considered the risks and benefits of this procedure and have discussed them with our family physician or other healthcare professional prior to coming to Gentle Procedures Clinic.
*
- I understand that complications after frenulectomy can occur, although the frequency varies with skill and experience of the doctor, and are infrequent at Gentle Procedures. Complications may include:
  - Significant post-op bleeding (1/100)
  - Phimosis or narrowing of the shaft-skin opening over the head of the penis (1/500)
  - Infection requiring antibiotics (1/1000)
  - Sub-optimal cosmetic outcome (1/500)
  - Meatal stenosis or narrowing of the urethra (1/1000)
  - Trauma to the head of the penis (never in this practice)
  - No change in my symptoms of premature ejaculation
  - Worsening of my premature ejaculation
  - Injury to the urethra including urethra-cutaneous fistula (1/1000)
  - More serious complications including death (never in this practice)
*
- I understand that it may be necessary for the doctor to use some or all of the following modalities to stop any bleeding should it occur:
  - Pressure dressings
  - Skin glue
  - Bipolar cautery
  - Suturing
*
- I know I must not take aspirin, anticoagulants (warfarin), or anti-inflammatories (NSAIDs) such as ibuprofen, naproxen, diclofenac, etc, 7 days before the procedure and for 2 days after.
Comments
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

Fax: 905-393-3748

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