We have carefully considered the risks and benefits of this procedure and have discussed them with our family physician or other healthcare professional prior to seeing Dr. Pollock.
We understand that, according to the College of Physicians and Surgeons of British Columbia Infant Male Circumcision (June 2004), the current medical consensus is that infant male circumcision is not a recommended routine therapeutic procedure.
We understand that we are making a consent by proxy for our infant for a non-therapeutic procedure. By signing this form, we have given our consent to this procedure as parents of this child.
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 agree to have our son circumcised by Dr. Neil Pollock. By signing this consent form we are acknowledging that the complications and risks of this procedure have been explained to us.
We understand that complications after circumcision can occur, although the frequency varies with the skill and experience of the doctor, and are infrequent in Dr. Pollock's practice. Complications include:
This consent form will be signed in the office.
- Significant post-op bleeding (1 in 400)
- Phimosis or narrowing of the shaft-skin opening over the head of the penis (1 in 500)
- Buried or trapped penis in the abdomen (1 in 800)
- Infection requiring antibiotics (1 in 1000)
- Meatal stenosis or narrowing of the urethra (1 in 1000)
- Sub-optimal cosmetic outcome (1 in 500)
- Trauma to the head of the penis (never in this practice)
- More serious complications including death (never in this practice)