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Print out ,read and sign this form and bring with you for the appointment with Dr Milton Sales
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\n\nBRUNKER ROAD MEDICAL CENTRE
\n\nCIRCUMCISION INFORMATION & CONSENT
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\nBaby's Name:
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Operation Date: Arrival Time: (information provided on booking consultation)
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\n\nCircumcisions will be performed in the procedure rooms of Brunker Road Medical Centre. You will be there for surgery for about 3hrs maximum. You will need to bring this consent form with you on the day of the procedure.
\n\nYour child will be given lignocaine anaesthetic cream, Paracetamol and Ordine Linctus orally as a premed, Sucrose Syrup orally and Lignocaine local anaesthetic by injection for this procedure.
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To bring on the day of the procedure:
\n\n4 disposable nappies on the day (disposable nappies are then to be used for 2 weeks post-surgery)
\n\tA DUMMY, this is essential for the administration of Sucrose Syrup during surgery
\n\tBETADINE ANTISEPTIC OINTMENT (Betadine First Aid Cream if ointment isnt available - but not liquid Betadine) to use on the wound with every nappy change for 3 days
\n\tTWO SPARE BABY BLANKETS or WRAPS
\n\tPlease dress your baby in ACCESSIBLE BABY CLOTHING that can easily expose the nappy region, whilst also keeping their top warm.
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\n\tHave at home for later use: Infant paracetamol (100mg/ml) may be given 4 hours after premedication, if needed for pain. DO NOT GIVE PARACETAMOL BEFORE THE SURGERY as nursing staff will administer a dose with the premedication. Have a fresh jar of Vaseline petroleum jelly; available for use from day 4 - for the next four weeks.
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\n\tThe risks of the procedure include:
Infection – 1 in 300 operation may require antibiotics
\n\tBleeding – 1 in 2,000 requiring ring removal to stop bleeding
\n\tBruising – which resolves without treatment
\n\tRing slipping back – 1 in 600 requiring ring removal
\n\tMedication reaction – very rare
\n\tBlood transfusion – 1 in 30,000 operations
\n\tRestriction of urethra by scarring later in life - rare
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\nI have been shown and understand the above risks and accept that this procedure is being performed at my request as the legal guardian of my child.
I understand that the consultation fee of $80* and operation fee of $400* are required to be paid to Dr Sales’ Secretary by cash, credit card or EFTPOS on the day. This operation is partly claimable from Medicare. A non-rebatable facility fee of $375* is also payable to Brunker Road Medical Centre for use of the procedure rooms and equipment.
\n*Subject to change without notification
\nHospital of Birth_______________________________________________________
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\nMedical problems with my child: _________________________________________
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\nInfections since birth: _________________________________________________
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\nFamily history of bleeding disorders e.g. haemophilia or Von Willebrands: ________________________
Please answer all questions, to the best of your knowledge, and sign before the consultation
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\nSigned: __________________________
\n\nName: _________________________
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\n\nKind Regards,
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\nDr Milton Sales