TO GENERATE A CUSTOMIZED LETTER TO HELP SUPPORT YOUR PFFR COMPLAINT:

Thank you for filling out this form on your son’s premature, forcible foreskin retraction (PFFR) incident. With this information, D.O.C. will generate for you a customized letter about the incident that you can send with a complaint to your state medical regulatory authority, or to the offending practitioner or facility. You will receive this customized letter by email, as an attached pdf, typically within a week. This information also helps us to document the problem of PFFR.

Please be assured that your information will be kept confidential, and your personal information will only be used for the purposes of aiding you in filing your complaint.

Asterix (*) indicates a required field.

  • NAME and CONTACT INFORMATION

  • Date Format: DD slash MM slash YYYY
  • BACKGROUND INFORMATION ABOUT THE INCIDENT

  • Date/time of retraction incident

  • Date Format: MM slash DD slash YYYY
  • [can choose more than one]
  • Where did the incident happen?

  • DESCRIPTION OF THE INCIDENT

  • • Suggested information to include: Whether you asked the medical professional not to retract your son and were ignored; how aggressively the doctor retracted your child’s foreskin; how far was your son retracted; your child’s reaction at the moment of retraction; was your child left with his foreskin fully retracted behind the glans (paraphimosis)?
  • • Suggested information to include: Your child’s condition over the next few days or weeks; whether your child bled, had swelling or discharge, or other signs of trauma or infection; what efforts you made to relieve your child’s distress; notes about your own distress and worry.
  • THANK YOU FOR THIS INFORMATION! You will receive your customized letter to support your forced retraction complaint soon, via the contact email you gave above.

  • IMPORTANT: PLEASE PRINT A COPY OF THIS FORM FOR YOUR RECORDS!

  • This field is for validation purposes and should be left unchanged.