Patient Consent Form Patient Details First Name Last Name D.O.B Contact No. Email Address Guardian Details First Name Last Name Contact No. I agree to the collection and use of my personal information above to aid in my treatment and for the purposes of appointment reminders so that we can be fair in allocating appointments to others, if you need to reschedule your appointment give us at least 24 hours notice. Patient Medical Information Do you have or have you had any of the following medical conditions? For all medical conditions marked as ‘Yes’ please consult your practitioner before your appointment. Heart Disease Yes No Diabetes Yes No Cancer Yes No High blood pressure Yes No Osteoporosis/ Arthritis Yes No Autoimmune disorders Yes No Excessive bleeding Yes No Gastrointestinal problems Yes No Lung problems Yes No Rheumatic fever Yes No Liver / kidney Problems Yes No Thyroid problems Yes No HIV and/or Hepatitis Yes No Artificial Joint or Valve Yes No Previously admitted to hospital or had a past operation? Yes No I am, or have recently undergone, chemotherapy or radiation therapy. Yes No Do you have any allergies? Yes No Do you have or have you had any of the following medical conditions? For all medical conditions marked as ‘Yes’ please consult your practitioner before your appointment. Please specify Do you smoke? Yes No Do you take medication? Yes No Has the patient experienced any previous issues related to the foreskin? Has the patient seen a general practitioner for such conditions? Yes No Any additional/other information: Method Of Circumcision Mogen Clamp Technique The penis is sanitized then locally numbed. The mogen clamp is placed over the head of the penis. The foreskin is removed using sterile tools. Risks Pain Bleeding Infection Irritation on the tip of the penis Meatitis Benefits Improved genital hygiene Reduced risk of urinary tract infections Reduced risk of phimosis after circumcision Reduced risk of HIV/AIDS Complications Serious complications requiring hospitalisation are rare (approximately 1 in 5000) The need for repeat surgery is not common at less than 1 in 1000 Post operative Instruction On the procedure day, Mr El Masri will provide you with care instructions and follow-up visits. A flyer will also be provided on the day outlining the step-by-step after care for your circumcision. Fees 0-3 WEEKS $400 3 WEEKS - 3 MONTHS $450 3 MONTHS - 12 MONTHS $500 1 YEAR - 3 YEARS $600 3 YEARS - 7 YEARS $700 7 YEARS - 12 YEARS $800 12 YEARS - 16 YEARS $900 16 YEARS - 22 YEARS $1000 22 YEARS - 40 YEARS $1300 40 YEARS AND OVERS $1500 Emergency Contact Name Contact No. Relationship How did you hear about us Walking by Staff member Google / Facebook / Website Flyer Family / Friend Terms and Conditions Please tick all boxes Whilst Mr. Louay El Masri is a recognised circumciser, please note he is not a doctor or general practitioner. The procedure executed by Mr Masri is for the purpose of ritual and is not a medical procedure. Mr. Masri is a third generation Ritual Circumciser with over 15 years of experience and will perform to the standards expected of a Ritual Circumciser. Mr. Masri is a designated member of the community whose expertise in this field will assist in your determination as to whether circumcision is the best decision for you, or your son. Mr. Masri’s circumcisions follows the traditional Islamic method for performing circumcisions on a person. Price may vary for the circumcision if the frenulum needs to be removed or any other skin conditions (these costs shall be disclosed prior to the procedure). Those who act aggressively, whether through behaviour or tone, may result in a termination of circumcision services. As we are a Ritual Circumcision Centre we are not associated with Medicare or Private Health Insurance and our services cannot be claimed under those providers. I acknowledge that the medical information I have provided is true and accurate at the time of completion and I have disclosed any medication or condition that may affect or influence my treatment. Payment on the day of treatment is required. Signature Date SUBMIT
