healthy kids care

You have requested that your doctor perform a circumcision on your child. This is a surgical procedure where the foreskin is removed from the penis. Once your authorization and consent is given, this procedure together with any different or further procedures which, in the opinion of the supervising doctor, may be indicated due to any emergency or previously unforeseen circumstances will be performed on your child. There is no guarantee as to the outcome of the procedure as all people heal differently and you acknowledge this has been adequately communicated. This procedure may involve risks or unsuccessful results, complications, injury, or even death from both known and unforeseen causes, and no warranty or guarantee is made as to the results.

Risk to circumcision include:

1. Bleeding; If you know of bleeding disorders, such as hemophilia in your family, please inform the doctor prior to authorization.
2. Infection.
3. Circumcision may result in severe scarring of the penis, which may interfere with the patient's later sexual activity.
4. 1 in 30 circumcisions need to be repeated at 2 years of age because of excess skin.
5. Damage to the penis.
6. Allergic reactions to the lidocaine (anesthetic used for the procedure).

After the risks and benefits of the circumcision procedure has been explained to me by:
Dr. Atousa Ghaneian M.D., F.A.A.P, I understand them and my questions have been answered to my satisfaction.

By signing this, you state you understand and assume full responsibility for knowing that complications may arise during or result from the procedure.