Glue

PATIENT IDENTIFICATION AREA

CONSENT FOR CIRCUMCISION

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TEACHING AFFILIATES OF HARVARD MEDICAL SCHOOL

I understand that circumcision is a procedure in which the foreskin (fold of skin that covers the end of the penis) is
surgically removed. Many parents are interested in having circumcision done for ethnic, cultural, religious or social
reasons; but there is still some medical controversy about the need for the procedure on a routine basis. The nature of
a circumcision, and the benefits to be reasonably expected compared with alternative approaches have been explained
to me.

I understand that there is a chance that risks or complications related to the circumcision may occur. These
complications include, but are not limited to the following:
Minor problems are short-term:
a. Slight oozing or slight bleeding may be noted at the surgical site
b. Infection of the circumcision site or at the tip of the penis can occur
c. Irritation of the exposed tip of the penis (glans) as a result of contact with stool or urine is not uncommon and
usually responds to cleansing with water
Long-term minor problems can include:
a. The urethra, which leads from the bladder to the tip of the penis, can be damaged at its point of exit.
b. Scarring of the penis can occur
c. Unintended removal of the outer skin layer (or layers) of the penis can occur.
d. An opening that is too small for the foreskin to retract over the penis can occur if too little foreskin is removed.
Major problems are very uncommon but can include:
a. Complete removal of the skin covering the shaft of the penis has rarely been reported.
b. Significant bleeding may occur, requiring stitches to stop the bleeding.
c. Serious, life-threatening bacterial infection can occur.
d. Partial or full removal (amputation) of the tip of the penis has also been rarely reported

_______________________________________________MD/NP will perform the procedure. The procedure may also

involve the participation of resident physicians, fellows and/or physician assistants. My physician will determine when it
is necessary for others to participate in the circumcision of my child.

I understand that blood or other specimens removed for necessary diagnostic or therapeutic reasons may later be
disposed of by the hospital. These materials also may be used by BWH or other academic or commercial entities, for
research, educational purposes (including photographing), or other activity, if in furtherance of the Hospital's missions.

Additional comments (if any):

The above risks and benefits have been explained to me. I have had an opportunity to fully inquire about the risks and
benefits of circumcision and its alternatives. All my questions were answered to my satisfaction and I consent to the
circumcision of my child.

Date____________ Time____________ AM/PM __________________________________________

Signature (Parent / Legal Guardian)

Date____________ Time____________ AM/PM __________________________________________ NP/M.D.

Signature (Practitioner)

MEDICAL RECORD COPY 0515195 (4/12)

2-Hole 1/4 2 3/4 - 3-Hole 1/4 4 1/4
 PATIENT IDENTIFICATION AREA

CONSENT FOR CIRCUMCISION

2-Hole 1/4 2 3/4 - 3-Hole 1/4 4 1/4

TEACHING AFFILIATES OF HARVARD MEDICAL SCHOOL

I understand that circumcision is a procedure in which the foreskin (fold of skin that covers the end of the penis) is
surgically removed. Many parents are interested in having circumcision done for ethnic, cultural, religious or social
reasons; but there is still some medical controversy about the need for the procedure on a routine basis. The nature of
a circumcision, and the benefits to be reasonably expected compared with alternative approaches have been explained
to me.

I understand that there is a chance that risks or complications related to the circumcision may occur. These
complications include, but are not limited to the following:
Minor problems are short-term:
a. Slight oozing or slight bleeding may be noted at the surgical site
b. Infection of the circumcision site or at the tip of the penis can occur
c. Irritation of the exposed tip of the penis (glans) as a result of contact with stool or urine is not uncommon and
usually responds to cleansing with water
Long-term minor problems can include:
a. The urethra, which leads from the bladder to the tip of the penis, can be damaged at its point of exit.
b. Scarring of the penis can occur
c. Unintended removal of the outer skin layer (or layers) of the penis can occur.
d. An opening that is too small for the foreskin to retract over the penis can occur if too little foreskin is removed.
Major problems are very uncommon but can include:
a. Complete removal of the skin covering the shaft of the penis has rarely been reported.
b. Significant bleeding may occur, requiring stitches to stop the bleeding.
c. Serious, life-threatening bacterial infection can occur.
d. Partial or full removal (amputation) of the tip of the penis has also been rarely reported

_______________________________________________MD/NP will perform the procedure. The procedure may also

involve the participation of resident physicians, fellows and/or physician assistants. My physician will determine when it
is necessary for others to participate in the circumcision of my child.

I understand that blood or other specimens removed for necessary diagnostic or therapeutic reasons may later be
disposed of by the hospital. These materials also may be used by BWH or other academic or commercial entities, for
research, educational purposes (including photographing), or other activity, if in furtherance of the Hospital's missions.

Additional comments (if any):

The above risks and benefits have been explained to me. I have had an opportunity to fully inquire about the risks and
benefits of circumcision and its alternatives. All my questions were answered to my satisfaction and I consent to the
circumcision of my child.

Date____________ Time____________ AM/PM __________________________________________

Signature (Parent / Legal Guardian)

Date____________ Time____________ AM/PM __________________________________________ NP/M.D.

Signature (Practitioner)

MEDICAL RECORD COPY 0515195 (4/12)

 FOR YOUR INFORMATION
Considerations for Non-Ritual Circumcision

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After the birth of a male infant, parents are asked whether they would like their son circumcised. Circumcision is the
surgical removal of all or part of the foreskin covering the end of the penis. A decision to circumcise or not to
circumcise a newborn son is a personal choice. Most newborn circumcisions are done for traditional, cultural or
religious reasons but even this choice should not be made without careful thought. We encourage you to read the
following information and discuss your decision with knowledgeable advisers; your obstetrician or midwife; and your
child’s pediatrician.
Reasons to Choose to have a Circumcision
1. Custom - In the United States, circumcision of the male infant is most commonly done by custom. Many parents
feel it is important that their son “looks like his father,” or peers.
2. Cleanliness - Circumcision does make cleanliness of the penis easier. A normal secretion, which is cream colored
and somewhat waxy, is formed under the intact foreskin. If allowed to accumulate, it can irritate the head of the
penis and may lead to an infection. Circumcision prevents this but the build-up can also be prevented by proper
hygiene during bathing. Circumcision does not eliminate the need for proper hygiene; though it does makes it
easier.
3. Decreased incidence of infection - Circumcision will slightly reduce the risk of urinary tract infections in males,
both as infants and also in adulthood. The incidence of such infections in the first year of life is reduced from 1 in
100 (hundred) to 1 in 1000 (thousand). Circumcision has also been shown to be associated with a lower risk for
some sexually transmitted infections, including HIV, particularly in areas where the use of safe sexual practices is
low
4. Prevention of paraphimosis - Rarely, parents may retract a still-tight foreskin while vigorously cleansing the penis
to eliminate the waxy secretion mentioned above. If the foreskin is left retracted, it can act as a tourniquet,
decreasing blood supply to the tip of the penis. This may need to be surgically corrected. Circumcision prevents
this uncommon complication from occurring.
5. Prevention of cancer of the penis - This is an extremely rare condition of adult-life. It is less common in
circumcised men and is usually found only in conditions of very poor hygiene, suggesting that proper hygiene
provides as much protection as circumcision.
Reasons to Choose NOT to have a Circumcision
1. Pain - Research and common sense lead to the conclusion that, in the absence of some form of analgesia (local
pain medicine), the infant experiences pain during the procedure. There are medications available that diminish
or eliminate pain, which are both safe and effective. The American Academy of Pediatrics recommends that these
be used. Clinicians in the Department of Obstetrics and Gynecology and the Division of Newborn Medicine at the
Brigham and Women’s Hospital routinely uses pain relief medication if circumcision is chosen and we urge you to
discuss this with your obstetrician.
2. Surgical risk - The vast majority of circumcisions are performed without any complications whatsoever. However,
no surgical procedure (and circumcision is a surgical procedure) can be totally risk-free. Complications include:
bleeding, infection, adhesion formation, cosmetic deformity, trauma to the penis, excessive removal of the
foreskin, and functional defects. These occur once every 500 circumcisions.
3. Change in sensation - Some believe that circumcision leads to a decrease in sexual pleasure later in life. There is
insufficient data to substantiate this belief.
4. Expense - There is a cost attached to the procedure. Some health insurance plans do not provide coverage for
circumcision. If you have concerns about your coverage, we urge you to contact your insurer before the procedure
is performed, as patients will be responsible for both hospital and physician charges.
Timing of circumcisions
Although parents have the option of delaying circumcision until a time beyond the newborn period, these “delayed”
circumcisions represent a more involved surgical procedure, usually performed with general or regional anesthesia. It
is important to note that 1 in 100 uncircumcised adults may require a circumcision for medical reasons.
Finally, in 1999, the Academy of Pediatrics Task Force on Circumcision concluded that, “...existing scientific evidence
demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to
recommend routine neonatal circumcision [and] ...parents should determine what is in the best interest of their child.”
The American College of Obstetricians and Gynecologists supports this statement. We support the conclusion that
parents are the best judges of the appropriateness or lack of appropriateness of circumcision for their children.