Are you a new or a returning patient?

New
Returning

Please choose your reason for visit:

Circumcision
Foreign Body Removal
I&D of Skin Abscess
Lip Tie Release
Lysis of Penile Adhesions
Soft Tissue Mass Excision
Tongue Tie Release
Tongue & Lip Tie Release
New Patient Consult

Please choose your reason for visit

Circumcision Follow-up
Established Patient
Foreign Body Removal
I&D of Skin Abscess
Lip Tie Release
Lysis of Penile Adhesions
Soft Tissue Mass Excision

Do both parents agree to circumcision?

Yes
No

Vitamin K shot at birth?

Yes
No

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

Yes, I acknowledge the increased risk of bleeding

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).

I agree to payment schedule

Baby’s age is less than 8 weeks.

Yes
No

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

Yes
No

Does your baby have jaundice?

Yes
No

Baby’s growth <5th percentile?

Yes
No

Photograph your Insurance Card

AboutLindsay Young, DNP

Are you a new or a returning patient?

Please choose your reason for visit:

Please choose your reason for visit

Do both parents agree to circumcision?

Vitamin K shot at birth?

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

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).

Baby’s age is less than 8 weeks.

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

Does your baby have jaundice?

Baby’s growth <5th percentile?

Modify your Appointment

Please Enter your Area/Zip Code

Photograph your Insurance Card

AboutLindsay Young, DNP

Are you a new or a returning patient?

Please choose your reason for visit:

Please choose your reason for visit

Do both parents agree to circumcision?

Vitamin K shot at birth?

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

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).

Baby’s age is less than 8 weeks.

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

Does your baby have jaundice?

Baby’s growth <5th percentile?

Modify your Appointment

Provider / Appointment Type Changed

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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).

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