(January 22, 2013)
Circumcision Consent Form
Ritual Jewish circumcision with direct oral suctioning (metzitzah b'peh) can only be performed after a parent has given written permission.
The consent form needs to be signed by both the mohel and at least one parent.
Download the Circumcision Consent Form.
Printed first and last name of individual performing circumcision:________________________________
Date of infant's birth (month/day/year): _________________________
I understand that direct oral suction will be performed on my child and that the New York City Department of Health and Mental Hygiene advises parents that direct oral suction should not be performed because it exposes an infant to the risk of transmission of herpes simplex virus infection, which may result in brain damage or death.
Printed first and last name of parent: __________________________________________
Signature of parent:________________________________________
Date of signature (month/day/year): ____________________________
A copy of this signed consent form shall be provided to the parent or legal guardian of the infant.
[The mohel does not need to sign the form, or give any contact details. Only one parent needs to sign it, even if the other bitterly disagrees with metzitzah or even circumcision. The form is not kept on file anywhere. There is no mechanism for ensuring that either parent sees it or signs it.]