© Dr Milton Sales

Circumcision Information Dr Milton Saleslick to edit me.

 

Print out ,read and sign this form  and bring with you for the appointment with Dr Milton Sales

BRUNKER ROAD MEDICAL CENTRE

CIRCUMCISION INFORMATION & CONSENT


Baby's Name:     

                                                                                   

Operation Date:                             Arrival Time:                     (information provided on booking consultation)

Circumcisions will be performed in the procedure rooms of Brunker Road Medical Centre. You will be there for surgery for about 3hrs maximum. You will need to bring this consent form with you on the day of the procedure.

Your child will be given lignocaine anaesthetic cream, Paracetamol and Ordine Linctus orally as a premed, Sucrose Syrup orally and Lignocaine local anaesthetic by injection for this procedure.

 

To bring on the day of the procedure:

  • 4 disposable nappies on the day (disposable nappies are then to be used for 2 weeks post-surgery)

  • A DUMMY, this is essential for the administration of Sucrose Syrup during surgery

  • BETADINE ANTISEPTIC OINTMENT (Betadine First Aid Cream if ointment isnt available - but not liquid Betadine) to use on the wound with every nappy change for 3 days

  • TWO SPARE BABY BLANKETS or WRAPS

  • Please dress your baby in ACCESSIBLE BABY CLOTHING that can easily expose the nappy region, whilst also keeping their top warm.


    Have at home for later use: Infant paracetamol (100mg/ml) may be given 4 hours after premedication, if needed for pain. DO NOT GIVE PARACETAMOL BEFORE THE SURGERY as nursing staff will administer a dose with the premedication. Have a fresh jar of Vaseline petroleum jelly; available for use from day 4 - for the next four weeks.

    The risks of the procedure include:

  • Infection – 1 in 300 operation may require antibiotics

  • Bleeding – 1 in 2,000 requiring ring removal to stop bleeding

  • Bruising – which resolves without treatment

  • Ring slipping back – 1 in 600 requiring ring removal

  • Medication reaction – very rare

  • Blood transfusion – 1 in 30,000 operations

  • Restriction of urethra by scarring later in life - rare


I have been shown and understand the above risks and accept that this procedure is being performed at my request as the legal guardian of my child. 

 I understand that the consultation fee of $80* and operation fee of $400* are required to be paid to Dr Sales’ Secretary by cash, credit card or EFTPOS on the day. This operation is partly claimable from Medicare. A non-rebatable facility fee of $375* is also payable to Brunker Road Medical Centre for use of the procedure rooms and equipment.
*Subject to change without notification


Hospital of Birth_______________________________________________________

Medical problems with my child: _________________________________________

Infections since birth: _________________________________________________

Family history of bleeding disorders e.g. haemophilia or Von Willebrands: ________________________

Please answer all questions, to the best of your knowledge, and sign before the consultation


Signed: __________________________

Name: _________________________

Kind Regards,


Dr Milton Sales