Circumcision Registration Form

Baby Information
Baby's First Name:
Baby's Last Name:
Date of Birth:	month January February March April May June July August September October November December day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 year 2007 2008 2009 2010 2011 2012 2013
Care Card Number (PHN) if Available:
Parent Information
Mother's Name:
Mother's Date of Birth:	month January February March April May June July August September October November December day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 year 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
Mother's Care Card Number (PHN):
Father's Name:
Father's Date of Birth:	month January February March April May June July August September October November December day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 year 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
Father's Care Card Number (PHN):
Contact Information
Address:
City:
Postal Code:	000-000
Home Phone:	000-000-0000
Cell Phone:	000-000-0000
Email:
Family Physician:
Family Physician's Phone Number:	000-000-0000
Family Physician's City:
Referring Physician:
Referring Physician's Phone Number:	000-000-0000
Referring Doctor's City:
Referring Healthcare Professional (i.e: nurse, midwife):
Referring Healthcare Professional's Phone Number:	000-000-0000
Referring Healthcare Professional's City:
Medical History
Has the baby had any medical or bleeding problems, or blood loss, since birth? Does your family have any history of bleeding problems?	choose one yes no
If yes, describe:
Were there any significant problems for baby or mother during delivery?	choose one yes no
If yes, describe:
Please list any medications your son is taking:
Medication Name / Dosage:	/
Medication Name / Dosage:	/

Circumcision Consent:

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: 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) This consent form will be signed in the office.