Please fill in this questionnaire to register for frenulectomy.

Once registration is complete the clinic will contact you to book your appointment.

Buenafe Clinic

Penile Frenulectomy Registration Form

First Name?

Last Name?

Birth Date?

Do you have a valid health card issued by the government of a Canadian province or territory?

Yes

Which Province/Territory issued your health card?

What is your PHIN number? (9 or 10 digit number on your health card)

What is your MHSC number? (Manitoba Health 6 digit number on your health card)

Street address?

Include the unit number if applicable

City/Town?

Province/Territory?

Postal Code?

Preferred phone number?

What is the best time to reach you?

Alternative phone number?

such as a work number

Email address?

Name of emergency contact?

What is your emergency contact's relationship with you?

Spouse

Father

Mother

Guardian

Friend

Uncle

Aunt

Grandfather

Grandmother

Son

Daughter

Grandson

Granddaughter

Nephew

Niece

Cousin

Other Relative

Emergency contact phone number?

How did you hear about us?

Online/Google

GP/Doctor's Referral

Friend/Family Member

Radio

Other

Please specify the other source that you heard about us

Reason(s) you are seeking a frenulectomy?

Select any that apply

Discomfort and bleeding

Premature ejaculation

Do you have a history of easy bruising?

Yes

Do you have nosebleeds with little or no trauma?

Yes

Have you ever had abnormal or prolonged bleeding after a dental procedure?

Yes

Did you have any medical or bleeding problems, or blood loss, since birth?

Yes

Does your family have any history of bleeding problems?

Yes

Do you have any reason to believe that you have low blood pressure or low hemoglobin?

Yes

Have you ever experienced fainting after an injection or medical procedure?

Yes

If not circumcised, have you ever considered a circumcision for medical or personal reasons?

Yes

If you haven’t already had a vasectomy, have you ever considered having one?

Yes

Please list any medications you are on, including name and dosage.

Press enter for newline

If not on any medication put "None". Include Aspirin, Advil, other anti-inflammatories.

Please list any allergies you have.

Press enter for newline

Put "None" if no known allergies

The referring physician's first and last name?

Referring physician's phone number?

Referring physician's clinic address?

What is your family physician's first and last name?

What is your family physician's clinic address?

What is your family physician's phone number?

I understand that complications after frenulectomy can occur, although the frequency varies with skill and experience of the doctor, and are infrequent in Dr. Buenafe’s practice. Complications may include:

• Significant post-op bleeding (1/100) • Phimosis or narrowing of the shaft-skin opening over the head of the penis (1/500) • Infection requiring antibiotics (1/1000) • Sub-optimal cosmetic outcome (1/500) • Meatal stenosis or narrowing of the urethra (1/1000) • Trauma to the head of the penis (never in this practice) • No change in my symptoms of premature ejaculation • Worsening of my premature ejaculation • Injury to the urethra including urethra-cutaneous fistula (1/1000) • More serious complications including death (never in this practice)

I understand

I understand that it may be necessary to use some or all of the following modalities to stop any bleeding should it occur:

• Pressure dressings • Skin glue • Bipolar cautery • Suturing

I understand

Dr. Buenafe has explained a frenulectomy may be beneficial. However, it does not qualify for billing under MSP. I request to pay privately for this procedure as per the clinic’s private fee schedule.

I understand

I understand that I must not take any anti-inflammatory medications in the 7 days before my procedure.

Examples: ADVIL, IBUPROFEN, ASPIRIN, MOTRIN, etc.

I understand

Signature

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Penile Frenulectomy Registration Form - Buenafe Clinic

Please fill in this questionnaire to register for frenulectomy.

Once registration is complete the clinic will contact you to book your appointment.

Penile Frenulectomy Registration Form

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