BLUE RIDGE PEDIATRIC & ADOLESCENT MEDICINE
ELECTIVE CIRCUMCISION CONSENT FORM
The informed consent process should be considered an important conversation between you and your health care provider. This procedure specific consent form has been written in lay terms and should convey to you the risks, benefits, alternatives as well as complications that could occur with your intended procedure. Reviewing this form will tell you what you can expect from receiving this treatment and/or procedure. The end of this form allows you and your doctor to attest that all questions have been answered to your satisfaction and that you the patient are giving informed consent to proceed with the treatment/procedure. You are advised to read this form carefully and use this opportunity as an information seeking session on the treatment/procedure you are about to undergo. If, after you have read and reviewed this form with your doctor, you do not believe that you truly understand the risk, benefits, and alternatives associated with the procedure do not sign the form until all your questions have been answered.
I understand that circumcision is an elective procedure and that some believe there are no actual benefits from an elective circumcision. Understanding this I request, I agree to allow
Dr. ______to perform an elective circumcision on ______ (name of child). This is a procedure that involves the removal of the normal male foreskin. I understand my child 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 by using the appropriate clamp or plastibell ring.
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, fever and/or possible decreased flow of urine. I understand that if my child does not urinate normally within six to eight hours after the circumcision, I am to follow the instructions below and contact my pediatrician. If a plastibell ring is used I understand that it may not fall off within 14 days of the procedure.
I understand that if any of these complications occur I am to contact my pediatrician immediately. Because of my child’s particular condition, these additional risks have also been explained to me: none
list ______
I understand that if such complications occur, my child may need to undergo additional medical procedures and/or be taken to the local 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 Dr. ______to perform such procedures at his/her discretion if needed during the procedure.
I consent for my child to receiving local anesthesia.
I confirm with my signature that: my physician has discussed the above information with me,
that I have had the chance to ask questions, that all of my questions have been answered to my satisfaction, and that I do hereby consent to the treatment described in this form.
______
Child’s name Child’s date of birth
______
Signature of responsible party Date
______
Print name Relationship
______
Witness to signature Date
Note to Witness
You have been asked to witness this procedure specific informed consent. Your signature to this form is intended to represent more than a “witness to a signature.” By witnessing this consent form you are acknowledging that you have asked the patient and the patient has confirmed to you that they have:
1. Read the form in its entirety,
2. Understand the form as it is written in lay terms,
3. Has had his or her questions satisfactorily answered and,
4. Chooses to proceed with the physician’s recommended treatment or procedure.
Physician
I confirm with my signature that I have discussed with the above-named child’s parent or guardian the risks, potential complications, and intended benefits of circumcision. The patient has had the opportunity to ask questions, all questions have been answered, and the parent or guardian has expressed understanding. Thus informed, the patient has requested that I perform a Circumcision on his/her child.
______
Physician signature Date
Circumcision Consent June, 2012 Page 1 of 2