Are you a new or a returning patient?

  • [[{"field_id":19664,"subrules":{"field_id":19662,"value":"New","operator":"Match"}}],[{"field_id":19665,"subrules":{"field_id":19662,"value":"Returning","operator":"Match"}}]]

Please choose your reason for visit:

  • [[{"field_id":19975,"subrules":{"field_id":19664,"value":"Circumcision","operator":"Match"}}]]

Please choose your reason for visit

Do both parents agree to circumcision?

  • [[{"field_id":19976,"subrules":{"field_id":19975,"value":"Yes","operator":"Match"}}]]

Vitamin K shot at birth?

  • [[{"field_id":19977,"subrules":{"field_id":19976,"value":"Yes","operator":"Match"}}],[{"field_id":19977,"subrules":{"field_id":19976,"value":"No","operator":"Match"}}]]

If your baby did NOT receive the Vitamin K shot, do you acknowledge the increased risk of bleeding during circumcision?

  • [[{"field_id":19978,"subrules":{"field_id":19977,"value":"Yes, I acknowledge the increased risk of bleeding","operator":"Match"}}]]

Parent/ Legal Guardian is willing to pay the out-of-pocket cost (total $800,
which is collected as follows: $400 deposit at time of scheduling appointment, and
the remaining balance of $400 is due 48 hours prior to the circumcision).

  • [[{"field_id":19979,"subrules":{"field_id":19978,"value":"I agree to payment schedule","operator":"Match"}}]]

Baby’s age is less than 8 weeks.

  • [[{"field_id":19980,"subrules":{"field_id":19979,"value":"Yes","operator":"Match"}}]]

My pediatrician has seen and evaluated the baby and has confirmed he is
healthy for circumcision.

  • [[{"field_id":19981,"subrules":{"field_id":19980,"value":"Yes","operator":"Match"}}]]

Does your baby have jaundice?

  • [[{"field_id":19982,"subrules":{"field_id":19981,"value":"No","operator":"Match"}}]]

Baby’s growth <5th percentile?