Skip to content
Print
Michael
2019-04-18T15:01:09-05:00
Agreement: Circumcision Consent
PATIENT INFORMATION
Patient Name
*
First
Last
Patient Date of Birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Patient Gender
*
Female
Male
KNOWN CONDITIONS AND ADDITIONAL RISKS
Are there any known bleeding problems that run in the family such as hemophilia, Von Willebrand disease, etc?
*
Yes
No
Don't Know
Did your child receive Vitamin K injection after birth?
*
Yes
No
Don't Know
Vitamin K injection is a standard medication given after birth to help prevent hemorrhagic disease of the newborn.
Additional Risk Acknowledgment
*
I understand that because of the patient’s known health condition(s), there are additional risks identified below.
Patient's Known Conditions
None
Explanation of Additional Risks
None
IMPORTANT IMFORMATION ABOUT THIS PROCEDURE
Circumcision Method
*
Plastibell Ring
Gomco
Procedure Consent
*
I do hereby agree and consent for the patient to undergo a circumcision.
I understand that circumcision is an elective procedure and that some believe there are no actual benefits from an elective circumcision. Circumcision is a procedure that involves the removal of the normal male foreskin. I understand the patient will be placed in a standard circumcision immobilization device. The penis will be draped and prepped. Local anesthesia will be administered and the foreskin removed.
I understand that there are risks and complications associated with this procedure and that these risks and complications are rare. The risks and complications include, but are not limited to, bleeding or infection at the site, and/or fever. I understand that if the patient does not urinate normally within eight hours after the elective circumcision or any of the disclosed complications occur, I am to contact my physician.
I understand that if complications occur, the patient may need to undergo additional medical procedures and/or be taken to a hospital for continued care. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to a physician to perform such procedures at his or her discretion if needed during the procedure.
I agree that this consent is written in lay-terms and conveys to me the risks and complications that could occur with elective circumcision.
I have been given the opportunity to ask questions regarding elective circumcision.
WHAT IS THE COST FOR THIS PROCEDURE?
Financial Responsibility
*
I understand my financial responsibility.
I understand that my insurance company may not consider elective circumcision medically necessary, and as a result, refuse to pay the charges. I also understand that some or all of the charges may go toward my deductible. If this occurs, I understand that I am required and agree to pay, in full, any amount not covered by my insurance company.
Insurance Company or Payment Method
*
Self Pay
BlueCross BlueShield
Cigna
Humana
UnitedHealthcare
Aetna
PHCS
HealthSmart
Averde Health
Estimated Cost for this Procedure
$0.00
PARENT OR LEGAL GUARDIAN CONSENT
Parent or Legal Guardian Name
*
First
Last
Consent to Circumcision Treatment
*
I consent to the procedure of elective circumcision.
I, (parent or legal guardian) consent, with my signature, to local anesthesia being administered to the patient. Furthermore, I confirm that a physician has discussed the above information with me. I’ve had the opportunity to ask questions. All of my questions have been answered to my satisfaction and I do hereby agree and consent for the patient to undergo the procedure of elective circumcision.
Parent or Legal Guardian Signature
*
Today's Date
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Page load link