Circumcision Information Dr Milton Sales and Dr Steven Lindsaylic
Print out ,read and sign this form and bring with you for the appointment with Dr Milton Sales or Dr Steven Lindsay
BRUNKER ROAD MEDICAL CENTRE
CIRCUMCISION INFORMATION & CONSENT
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
Dr Milton Sales
Dr Steven Lindsay