Penile Frenulectomy Registration

Patient Information

Name*(Required)

First Last

Date of Birth*(Required)

Address*(Required)

Street Address Address Line 2 City Province Postal Code

Preferred Phone*(Required)

Email*(Required)

Emergency Contact Name*(Required)

First Last

Emergency Contact Phone*(Required)

Family Doctor

First Name Last Name

Family Doctor's Phone Number

Family Doctor's Medical Centre or Workplace

How did you hear about us?*(Required)

Online / Google

GP / Doctor's Referral

Friend or Family Member

Other

Please specify

Reasons you are seeking a frenulectomy (select all that apply):*(Required)

Discomfort and bleeding

Premature ejaculation

Allergies

Do you have any allergies?*(Required)

Yes

If yes, please describe:

Medical History

Do you have a history of easy bruising?*(Required)

Yes

Do you have nosebleeds with little or no trauma?*(Required)

Yes

Have you ever had abnormal or prolonged bleeding after a dental procedure?*(Required)

Yes

Did you have any medical or bleeding problems, or blood loss, since birth?*(Required)

Yes

Does your family have any history of bleeding problems?*(Required)

Yes

Do you have any reason to believe that you have low blood pressure or low hemoglobin?*(Required)

Yes

Have you ever experienced fainting after an injection or medical procedure?*(Required)

Yes

If yes, please describe:

Please list any medications you are taking. Enter "none" if none.*(Required)

(name/dosage)

Consent

You must consent to the following:

I have carefully considered the risks and benefits of this procedure and have discussed them with our family physician or other healthcare professional prior to coming to Gentle Procedures Clinic.

I understand that complications after frenulectomy can occur, although the frequency varies with skill and experience of the doctor, and are infrequent at Gentle Procedures. 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 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

I know I must not take aspirin, anticoagulants (warfarin), or anti-inflammatories (NSAIDs) such as ibuprofen, naproxen, diclofenac, etc, 7 days before the procedure and for 2 days after.

Phone

This field is for validation purposes and should be left unchanged.

Patient Information

Allergies

Medical History

Consent

Gentle Procedures

Services

Appointments