CIRCUMCISION REGISTRATION FORM

Please take the time to review the information provided on this website as well as in the Circumcision Information Package.

We also welcome you to print the information package, and jot down your questions, so that we can refer to them when we review the instructions with you.

To facilitate the appointment booking process, please fill out the following Online Registration form.

Alternatively, you can call the clinic directly at (613) 244-4400.

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Registration Form

PERSONAL INFORMATION

PARENT INFORMATION

CONTACT INFORMATION

PHYSICIAN INFORMATION

MEDICAL HISTORY

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CONSENT

Note – You will be asked to sign this consent form at your appointment.

We have carefully considered the risks and benefits of the Gomco infant circumcision.

We understand the procedure details and all of our questions have been answered.

We understand that, according to the American Academy of Pediatrics (AAP), the health benefits of newborn male circumcision outweigh the risks, but the benefits are not great enough to recommend universal newborn circumcision. Also, the Canadian Paediatric society (CPS) adds that the decision may ultimately be based on personal, religious or cultural factors.

We understand that, as parents of this child, we are giving consent by proxy for our son to have a circumcision.

We agree to have our son circumcised by Dr. Marc Brulotte. By signing this consent form, we are acknowledging that the complications and risks of this procedure have been explained to us.

We consent to the administration of oral sucrose as well as local anaesthesia (xylocaine 1%).

Although rare, we understand that complications after circumcision may occur. These may include and are not limited to:

  • Post-operative bleeding
  • Infection requiring antibiotics
  • Sub-optimal cosmetic outcome, adhesions and phimosis (narrowing of the terminal portion of skin)
  • Trauma to the head of the penis