| Patient | Date of birth | Age | Date |
Circumcision: surgical excision of the prepuce (foreskin), the tissue covering the glans of the penis.
No medical condition requiring surgical intervention has been diagnosed in this patient. This procedure is being requested on an elective, non-therapeutic basis.
As with any surgical procedure, risks include but are not limited to:
The overall complication rate across large pooled studies of elective circumcision is approximately 3.3%. Meatal stenosis is not included in that figure: studies designed specifically to detect it find it in a substantial minority of circumcised boys, and it is very uncommon in boys who are not circumcised.
Section 3 describes outcomes that may or may not occur. The outcomes below are not complications: they occur in every case where the procedure is completed as intended, and are not a sign anything went wrong.
Circumcision is associated with a reduction in the incidence of urinary tract infection in infancy, from approximately 1% to approximately 0.1%, on the order of 111 procedures performed for each infection prevented.
Note: Circumcision has NOT been shown to provide statistically significant protection against HIV or other sexually transmitted infections in the largest cohort studies conducted in countries comparable to this patient's, including national cohorts of over 800,000 men in Denmark and over 550,000 men in Ontario, Canada.
Circumcision is associated with a reduced lifetime risk of penile cancer, a rare cancer with a median age at diagnosis of age 68.
A circumcised penis requires marginally less time to wash, saving on the order of a few seconds per shower.
The alternative to this procedure is to not perform it. The foreskin separates from the glans naturally over a period of months to years in almost all boys and requires no specific care beyond routine external washing during this time. No treatment is required for this natural process, and it is not evidence of a medical problem.
This procedure remains available to the patient at any later date in his life, should he choose it, with his own informed consent. No later procedure can restore tissue removed at this stage.
The patient is a newborn and is not capable of providing or withholding consent. No proxy measure fully substitutes for his own informed decision.
The best available indication of the preference he might express, if he could: in populations where the decision is left to the individual rather than made in infancy, it is overwhelmingly declined.
This procedure is billable separately from the birth admission under its own procedure code. The physician who recommends this procedure is frequently the same physician who performs it and is compensated for doing so.
No. This is an independent template published by The Case to Wait, an educational activism project — not a hospital, clinic, or medical provider. No signature on it has any legal effect.
Most circumcision consent forms in actual use list surgical risks but omit the certain, non-risk effects of the procedure (Section 4), the fact that the patient cannot consent for himself (Section 7), and the physician's financial interest in performing it (Section 8). This template includes them so parents can see what a more complete informed-consent disclosure would look like.
Yes — it's free to print, copy, and adapt. It's offered as an educational reference and a model of a more complete disclosure, not as a legal or medical document.