Consent Form

Consent Form for Infant Male Circumcision (UK)

This form must be completed and signed by the parent(s) or legal guardian(s) of the infant
undergoing circumcision. Please read all sections carefully and ask any questions you may
have before signing.
Infant Details
Full Name of Infant: __________________________________
Date of Birth: _______________________________________
NHS Number (if available): _____________________________
Parent/Guardian Details
Full Name of Parent/Guardian 1: ________________________
Relationship to Infant: ________________________________
Signature: _______________________ Date: _____________
Full Name of Parent/Guardian 2 (if applicable): __________
Relationship to Infant: ________________________________
Signature: _______________________ Date: _____________
GP Details
GP Name:
GP Surgery
Procedure Information
Circumcision involves the removal of the foreskin from the penis. This is a surgical
procedure often performed for cultural, religious, or medical reasons. The procedure will be
performed by a qualified healthcare professional under local anaesthetic.
Benefits
The benefits of circumcision may include reduced risk of certain infections and hygiene
improvement.
Risks and Complications

As with any surgical procedure, there are risks which include BLEEDING, URINARY
RETENTION, INFECTION, PAIN, SWELLING, BRUISING, TOO MUCH OR TOO LESS SKIN
REMOVAL, SCAR TISSUE, MEATAL STENOSIS, FISTULA FORMATION, COMLICATIONS
RELATED TO LOCAL ANAESTHETICS INCLUDING ALLERGIC REACTION.
Consent Statement
I/ WE CONFIRM A WRITTEN AFTERCARE ADVICE LEAFLET HAS BEEN PROVIDED AND I
/WE HAVE HAD AN OPPORTUNITY TO DISCUSS WITH THE DOCTOR ANY QUESTIONS I/WE
MAY HAVE IN RELATION TO THE PROCEDURE.
I/WE AGREE THAT I HAVE PARENTAL RESPONSIBILITY FOR THE PATIENT. ALSO, ALL
THOSE WITH PARENTAL RESPONSIBILITY ARE AWARE OF THE PROCEDURE DESCRIBED
ABOVE TO BE CARRIED OUT WITHOUT ANY DISAGREEMENT OR DISPUTES.
I/WE AGREE AND UNDERSTAND OF THE RISK INVOLVED AND HAVE NO FURTHER
QUESTIONS. I/ WE WILL HAVE THE OPPORTUNITY TO DISCUSS ANY DETAILS WITH THE
PERSON PERFORMING THE PROCEDURE BEFORE THE PROCEDURE IS CARRIED OUT.
I/WE HAVE THE RIGHT TO CHANGE MY MIND AT ANY TIME, INCLUDING AFTER I HAVE
SIGNED THIS FORM
Mother’s Signature Father’s Signature

Interpreter (if applicable)
Name of Interpreter: _________________________________
Language: __________________________________________
Signature: _______________________ Date: _____________
Healthcare Professional Declaration
I have explained the nature, purpose, risks, and benefits of the procedure to the
parent(s)/guardian(s).
Name: ______________________________________________
Position: ____________________________________________
Signature: _______________________ Date: _____________