Patient Name:

Age:

Date:

Procedure: Adult Circumcision

Indications:

Patient is a male patient with redundant prepuce/phimosis/ genital warts who desires circumcision.

Alternatives:

To include watchful waiting and dorsal slit have been discussed.

Risks/Complications:

These include but are not limited to: hemorrhage, pain, wound infection/ dehiscence, removal of to little skin, removal of to much skin, and meatal stenosis. In addition the seriousness of the patient�s medical problems have been discussed in depth. The risks of myocardial infarction, heart failure, stroke, death and long-term stay in the Intensive Care Unit (ICU) have been raised with you. Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal headache, nerve damage, spinal canal bleeding, infection and death. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary. You understand the procedure as discussed, and agree to proceed with the procedure

Physician's Signature: ________________________________ Date: __________________

Patient Signature: __________________________________ Date: __________________