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PATIENT INFORMATION

Patient Name*

First Last

Patient Date of Birth*

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

Explanation of Additional Risks

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*

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*

Agreement: Circumcision Consent

PATIENT INFORMATION

KNOWN CONDITIONS AND ADDITIONAL RISKS

IMPORTANT IMFORMATION ABOUT THIS PROCEDURE

WHAT IS THE COST FOR THIS PROCEDURE?

PARENT OR LEGAL GUARDIAN CONSENT