Consent For Circumcision And Consent For Electronic Communication And Virtual Care Tools
Last Updated: Jan 20, 2025
Consent for CIrcumcision:
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, as well as health prevention and hygiene reasons but this choice should not be made without careful thought. The nature of a circumcision, and the benefits to be reasonably expected, compared with alternative approaches, and the risks have been explained to me.
I understand that there is a chance that risks or complications related to the circumcision may occur. Some of these complications may require future surgical intervention. These complications include, but are not limited to, the following:
Minor short-term problems:
Slight oozing or slight bleeding
Infection of the circumcision site or at the tip of the penis
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
Minor long-term problems:
The urethra, which leads from the bladder to the tip of the penis, can be damaged at its point of exit Scarring of the penis
Unintended removal of the outer skin layer (or layers) of the penis
The site of foreskin removal can scar, leaving an opening too small for the skin to retract over the penis
Major problems that are very uncommon:
Complete removal of the skin covering the shaft of the penis has rarely been reported
Significant bleeding may occur, requiring stitches or other measure to stop the bleeding
Serious, life-threatening bacterial infection can occur
Partial or full removal (amputation) of the tip of the penis has been rarely reported
By signing this consent, I acknowledge that the nature of the procedure and the risks of circumcision have been explained to me. I have had an opportunity to fully inquire and ask questions about the risks and benefits of circumcision and its alternatives. All of my questions were answered to my satisfaction, and I consent to the circumcision of my child. I have received and reviewed written information about the procedure, after-care instructions, and all concerning signs/symptoms. I understand all reasons to seek medical attention or present to the emergency department (ER) following this procedure.
Consent to Electronic Communication And Virtual Care Tools:
The Circumcision Clinic medical and administrative team (“the Clinic”) has offered to provide communication by electronic medical record portal, telephone, email and text messaging, including instant messaging (“the Services”):
PATIENT ACKNOWLEDGMENT AND AGREEMENT:
The Clinic will use reasonable means to protect the security and confidentiality of information sent and received using the Services (“Services” is defined in the attached Consent to use virtual care tools). However, because of the risks outlined below, the Clinic cannot guarantee the security and confidentiality of all virtual care tools:
Use of virtual care tools to discuss sensitive information can increase the risk of such information being intercepted by third parties. Despite reasonable efforts to protect the privacy and security of information communicated through virtual care platforms, it is not possible to completely secure the information. Employers and online services may have a legal right to inspect and keep electronic communications that pass through their systems. Virtual care tools can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, and security settings. Communications through virtual care tools can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Clinic or the patient. Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.Communications through virtual care tools may be disclosed in accordance with a duty to report or a court order. Some video conferencing platforms may be more open to interception than other forms of videoconferencing.
If email or text is used as a virtual care tool, the following are additional risks: Email, text messages, and instant messages can more easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients. Email, text messages, and instant messages can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has been sent.
Conditions of using the Services:
While the Clinic will attempt to review and respond in a timely fashion to electronic communications such as electronic medical record portal messages, emails, text messages, and instant messages, the Clinic cannot guarantee that all electronic communications will be reviewed and responded to within any specific period of time.
The Services will not be used for medical emergencies or other time-sensitive matters.
If your electronic communication requires or invites a response from the Clinic and you have not received a response within a reasonable time period, it is your responsibility to follow up to determine whether the intended recipient received the electronic communication and when the recipient will respond.
Virtual care is not an appropriate substitute for in-person communication or clinical examinations, where appropriate, or for attending the Emergency Department when needed.
You are responsible for following up on the Clinics electronic communication and for scheduling appointments where warranted.
Electronic communications or recordings of virtual encounters concerning diagnosis or treatment may be printed or transcribed in full and made part of your medical record.
Other individuals authorized to access the medical record, such as staff and billing personnel, may have access to those communications and recordings.
The Clinic may forward electronic communications or recordings to staff and those involved in the delivery and administration of your care.
The Clinic might use one or more of the Services to communicate with those involved in your care.
The Clinic will not forward electronic communications or recordings to third parties, including family members, without your prior written consent, except as authorized or required by law.
The Clinic is not responsible for information loss due to technical failures associated with your software or internet service provider.
Instructions for using the Services:
To use the Services, you must:
Reasonably limit or avoid using an employer’s or other third party’s computer.
Conduct virtual care encounters in a private setting and using a secure device, where possible.
Obtain the Clinic’s consent prior to making any recording of the virtual care encounter.
Inform the Clinic of any changes in the patient’s email address, mobile phone number, or other account information necessary to communicate via the Services.
If the Services include email, instant messaging and/or text messaging, the following applies:
Include in the message’s subject line an appropriate description of the nature of the communication (e.g. “prescription renewal”), and your full name in the body of the message.
Review all electronic communications to ensure that they are clear and that all relevant information is provided before sending to the Clinic.
Ensure that the Clinic is aware when you receive an electronic communication from the Clinic, such as by a reply message or allowing “read receipts” to be sent.
Take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.
Withdraw consent only by email or written communication to the Clinic.
If you require immediate assistance, or if your condition appears serious or rapidly worsens, you should not rely on the Services rather you should call the Clinic’s office or take other measures as appropriate, such as calling “911” or going to the nearest Emergency Department or urgent care clinic.
I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected Services. I understand and accept the risks outlined in this consent form, associated with the use of the Services when interacting with the Clinic. I consent to the conditions and will follow the instructions outlined, as well as any other conditions that the Clinic may impose in relation to patients using the Services.
I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for virtual care tools, it is possible that interacting with the Clinic using the Services may not be encrypted. Despite this, I agree to interact with the Clinic using these Services with a full understanding of the risks.
I acknowledge that either I or the Clinic may, at any time, withdraw the option of using the Services upon providing notice. Any questions I had have been answered.