Patient Name:

Age:

Date:

Procedure: Meatotomy (pediatric)

Indications:

Patient is a male child with meatal stenosis

Alternatives:

Alternative to this procedure is observation.

Risks/Complications:

The risks and complications of the procedure where extensively discussed with the parent(s). The general risks of this procedure include, but are not limited to bleeding, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures, deep venous thrombosis, pulmonary embolus, death or a long-term stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal head-ache, nerve damage, spinal canal bleeding and malignant hyperthermia. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary.

The specific risks of this procedure include, but are not limited to: persistent penile glans bleeding, pain on urination, re-stenosis, to large of meatal opening, to small of meatal opening, and may be dissatisfied with cosmetic result.

You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.

Physician's Signature: ________________________________ Date: __________________

Parent Signature: __________________________________ Date: __________________