Register for Circumcision

Completing this form will place your baby on Dr. Hansen’s waitlist for circumcision.
Please review the Circumcision Information and FAQ pages prior to registering.

One of our office staff will contact you within 1 week to book the circumcision.
If you have not heard back 1 week after submitting this form, please call 604-888-2433 to follow up.

Once submitted, you will be redirected to the Circumcision Preparation page.

Baby's name

First Name

Last Name

Baby's PHN (Care Card) number

Date of birth

MM

DD

YYYY

Age (in days)

Birth weight

Mother's name

First Name

Last Name

Father's name

First Name

Last Name

Phone number

(###)

###

####

Alternate phone number

(###)

###

####

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Family physician