I understand that there is a chance that risks or complications related to 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 gentle 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

I have reviewed these risks and consent to the procedure for my infant to be performed by Dr. Sandra Herron at Roadrunner Pediatrics. 

Financial Policy for Circumcisions: Newborns have 30 days from birth to be added to your insurance. If your insurance pays for circumcisions, we will hold a credit card on file AND NOT CHARGE IT while we wait for confirmation from you that your baby is added and active on your insurance. After 30 days, if we have not heard from you to confirm this, or if you are not able to get your newborn on your insurance, we will call you to let you know that we are charging your card and you can submit the receipt to your insurance company for reimbursement. 

If your insurance does not cover circumcisions, there is a fee for circumcisions due at the time of service. Please call our office for details. 

Please do not hesitate to ask us if you have questions about this policy. 

My signature below confirms that I have read the risks of circumcision and the circumcision financial policy and that my baby has received the Vitamin K shot in the hospital after birth: