Please fill in this questionnaire to register.

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

Buenafe Clinic

Adult Circumcision Registration

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?

Home phone number?

Mobile phone number?

Email address?

Name of emergency contact?

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

Have you had any medical or bleeding problems, or blood loss, since birth? Does your family have any history of bleeding problems? Do you have any reason to believe that you have low blood or low hemoglobin?

Press enter for newline

Put "None" or specify the problem(s)

Please list any medications being taken, 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

Press enter for newline

Put "None" if no known allergies

Family Physician Name?

Family physician clinic phone number?

If you do not know the phone number enter the clinic name where you see your family doctor.

Referring Physician Name?

Can leave blank if you were not referred.

Referring physician phone number?

Can leave blank if you were not referred. If you do not know the phone number enter the name of the clinic where the referring doctor saw you.

I have carefully considered the risks and benefits of this procedure and have discussed them with my family physician or other healthcare professional.

Yes

I understand that Buenafe Clinic is one of the few clinics offering circumcision on adults under local anesthesia and they have explained to me this new approach.

Yes

I understand that complications after circumcision can occur, although the frequency varies with the skill and experience of the doctor, and are infrequent at Buenafe Clinic. 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) Buried or trapped penis in the abdomen (1/800) Infection requiring antibiotics (1/1000) Meatal stenosis or narrowing of the urethra (1/1000) Sub-optimal cosmetic outcome (1/500) Trauma to the head of the penis (never in this practice) Injury to the urethra including urethra-cutaneous fistula (1/1000) More serious complications including death (never in this practice)

Yes

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

Pressure dressings Skin glue Bipolar cautery Suturing

Yes

The doctor has explained that, in their opinion, circumcision would be beneficial. However, they do not believe it qualifies for classification as medically necessary, according to Manitoba Health requirements and does not meet Manitoba Health guidelines to bill Manitoba Health for a non-medically necessary service. I request to pay privately for this procedure as per the Buenafe Clinic private fee schedule.

Yes

I confirm that I understand that I must not take any anti-inflammatory medications in the 7 days before my procedure. Examples: ADVIL, IBUPROFEN, ASPIRIN, MOTRIN, etc.

Yes

I understand that scheduling procedures requires careful planning and coordination between the facility, doctor, and support staff necessary for the procedure. In addition, special medical instrumentation is prepared and sterilized for each individual procedure. Therefore, any cancellation or no-show with less than 2 weeks notice will incur a $150.00 fee.

Yes

I agree to be circumcised by Dr. Buenafe. By submitting this consent form I am acknowledging that the complications and risks of this procedure have been explained to me.

Yes

Who completed the registration form today?

Enter name and relation to patient.

Signature

Adult Circumcision Registration - Buenafe Clinic

Please fill in this questionnaire to register.

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

Adult Circumcision Registration

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