Register:

Holistic Circumcision Registration Form:

The following information will be needed after the circumcision has been scheduled and confirmed. Please do not email or fax this information to me before the baby has been born.

Thank you.

Registration Form

Event

Day: Monday Tuesday Wednesday Thursday Friday Saturday Sunday     Date: (MM/DD/YYYY)   

Time: AM Noon PM

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Father/Parent 1 (or Single Parent)

Last name:    First name:

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Mother/Parent 2

Last name:    First name:

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Contact email address:

Contact cell phone number: ( ) -

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Baby

Last name:    First name:    Middle name(s):    

Date of birth? (MM/DD/YYYY)   Time of birth? AM Noon PM Midnight

Birth weight? lbs. oz.   Birth Length? 17" or less 17.5" 18" 18.5" 19" 19.5" 20" 20.5" 21" 21.5" 22" 22.5" 23" 23.5" 24" or more

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Second baby

Last name:    First name:    Middle name(s):    

Date of birth? (MM/DD/YYYY)   Time of birth? AM Noon PM Midnight

Birth weight? lbs. oz.   Birth Length? 17" or less 17.5" 18" 18.5" 19" 19.5" 20" 20.5" 21" 21.5" 22" 22.5" 23" 23.5" 24" or more

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Was it a c-section? Yes No

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Is there anything that would impede or affect the healing of the circumcision?
Yes No
If "Yes" please explain:


Is there any history of bleeding disorders in your families?
Yes No
If "Yes" please explain:


Is there any reason the baby cannot be circumcised?
Yes No
If "Yes" please explain:

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Did you read and print the Supply List from my web site? Yes No.

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Home Address

(I will need directions only if it is a new development or the address is not found on Waze or Google Maps. Please email the directions to:  )

Street Address:     Apartment # (If applicable)

City:    State:    Zip:

Home phone number: ( ) -

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Event Address (if not at home)

(I will need directions only if it is a new development or the address is not found on Google or Mapquest.) Please email the directions to: )

Name of Institution (if applicable):

Address:

City:    State:    Zip:

Phone number: ( ) -   or Email address:

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Additional Information

Who referred you to me? Did previous child Family Friend Rabbi Synagogue Caterer Pediatrician Obstetrician Midwife Doula Nurse Other

Last Name   First Name

Phone number? ( ) -   or Email address:


Did you give birth at: Home Hospital

Name of Hospital:

City:     State:    Zip:

Phone number: ( ) -   or Email address:


Who is your Pediatrician?

Last Name:   First Name:

Phone number? ( ) -   or Email address:


Who delivered your baby? Ob/Gyn Midwife

Last Name:   First Name:

Phone number? ( ) -   or Email address:   


Who is helping you at home? Nurse Doula Mother Mother-in-law None

Last Name:   First Name:

Phone number: ( ) -   or Email address:

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FINALLY (and this is the ONLY compulsory question):

I have read and understand the Risks, Benefits and Alternatives to performing a Brit Milah/Holistic Circumcision. I affirm that all of the information above is accurate and true.

Please type the word "baby" in the box below to prove that you are a human being.
(It helps prevent automated spammers.) Thank you.

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