Same Day Frenulectomy & Frenuloplasty Form - Circumcision Vasectomy Australia

Frenulectomy & Frenuloplasty Intake

First Name

Last Name

Phone/Mobile

Can you pull down your foreskin?

Yes

Not applicable ( I don't have a foreskin)

Have you got a bleeding disorder?

Yes

Do you suffer from any genetic conditions?

Yes

Do you take any blood thinning medications? e.g. Aspirin, Fish Oil, Warfarin or any other anticoagulants?

Yes

Do you suffer from Diabetes?

Yes

Do you suffer from any autoimmune conditions?

Yes

Do you have any allergies?

Yes

Please list your allergies

Which location would you like your Frenulectomy/Frenuloplasty?

Dandenong

Hoppers Crossing

East Melbourne

Craigieburn

We will contact you to book your frenulectomy/frenuloplasty.
Your frenulectomy/frenuloplasty will be confirmed upon receiving a $200.00 deposit.
You can pay your deposit online. We will send you a link to pay your deposit after we have booked a date for your frenulectomy/frenuloplasty.
Your deposit must be paid within 48 hours from your phone call.

Same Day Frenulectomy or Frenuloplasty Procedure