Baby Circumcision Intake Form

This form is only for boys LESS than 4 months old

Circumcision intake form (less than 4mths)

Child’s First Name

Child’s Last Name

Email

Phone/Mobile

Age (weeks)

Does your son suffer from any medical conditions?

Yes

No

Does your son take any medication?

Yes

No

Does your son have a history of surgery?

Yes

No

Do you, your son or your son’s other parent suffer from any allergies?

Yes

No

Please list these allergies

Do you, your son or your son’s other parent suffer from a bleeding disorder?

Yes

No

Do you, your son or your son’s other parent suffer from any genetic conditions?

Yes

No

Which location would you like your son’s circumcision?

Dandenong

Hoppers Crossing

South Melbourne

Coolaroo

What time/day would you like us to contact you (Mon-Fri)?

Mon (9am – 1pm)

Mon (2pm – 5pm)

Tue (9am – 1pm)

Tue (2pm – 5pm)

Wed (9am – 1pm)

Wed (2pm – 5pm)

Thurs (9am – 1pm)

Thurs (2pm – 5pm)

Fri (9am – 1pm)

Fri (2pm – 5pm)