You can find the Intact Care Agreement
here. I personally saved it to my computer then modified it to better suite my needs. Here is the AAP Intact Care Guide
that I have to go alone with it. Specifically that part about retraction.
Intact Care Agreement
The Health Care Provider/s of our son.
The parents ofAs our son's parents, we have written this document as a preventative measure only, in response to a previous
negative experience. It is not meant to single out any one person, but is meant to relay our wishes and
concerns to all health care providers who see our son.
In providing health care for the above named person, I agree to the following:
This boy is not circumcised. He was left intact, on purpose, by his parents at birth, who refused the
operation at that time, as they feel that it is not a medically indicated procedure for infants. They intend to
keep him intact, and are informed on the proper (and wary of the improper) care of the intact penis.
The proper care of the intact penis is to "leave it alone" AAP, American Academy Of Pediatrics (See
attached printout) and other health care organizations. His parents do not retract his foreskin, (push it back at
all toward the body) as it is unnecessary & harmful, likewise will not allow anyone else to do so either. The
foreskin is firmly attached to the glans (head) of the penis in much the same way as the fingernail is attached
to the finger, and DOES NOT retract.
Furthermore, any retraction of the foreskin before natural separation has occurred can cause irreparable
damage through bleeding and the formation of adhesions. The ONLY person who may retract our son's
foreskin is our son himself.There is NO reason whatsoever to touch our son's penis during an exam:
Not "To see inside"; not "Out
of curiosity"; not "To break adhesions (the attach points are synechiae & are supposed to be there, not
adhesions)"; not "To see if the foreskin retracts"; not "To clean it", etc., etc.
The intact penis requires no special care, such as "irrigation" or "loosening of the foreskin". His parents
wipe the OUTSIDE with soapy water at bath time (and rinse after with warm water), and with water or baby
wipes at each diaper change. Any "cleaning" other than the afore-mentioned can cause infection, and
problems which stem from infections.I, as the health care provider of the above named, have read this document and I understand what I have
read, fully, and therefore agree that I will not touch his penis for any reason. If I genuinely have a
concern about whether his urethral opening is "fine", I will bring this point up to his parents and they can
decide if there needs to be anything done. If they DO decide that it needs to be looked at, only THEY, not I,
will touch his penis.
I will adhere to the above information, and know that, if I do not, it will be seen in the eyes of his parents,
as purposeful abuse toward their son. If I do not agree to all that is written here, I of course have the right to
refuse to treat this child and he will not be looked after by me for his medical care.
Care Givers Signature: Date:Edited by MCatLvrMom2A&X - 1/12/11 at 4:07pm