Rabbi Shlome Ekstein
Certified Mohel · Brit Milah for Infants and Adults

Adult Brit Milah — Confidential Intake

Thank you for reaching out. Choosing a brit as an adult takes real courage and commitment, and it is a privilege to help you enter the covenant of Avraham Avinu.

What to expect. This form takes about 10 minutes. It has five short parts: about you, your brit, your medical history, scheduling, and the consent form (which you can also sign in person instead). Everything you share is kept private and is seen only by Rabbi Ekstein.

After you submit, Rabbi Ekstein will personally call you to talk things through and answer every question — nothing is scheduled until you've spoken. Sending this form is not a commitment. Even if you sign the consent online, you can still ask anything or change your mind at any time before the procedure.

Prefer to talk first? Call 845-467-8595.

About you

So we can reach you and keep you safe on the day.

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Not required — many people choose one at the brit.
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This form is for adults 18 and older. For a younger person, please call 845-467-8595 directly.
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Please check the email address
Best way to reach you
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Emergency contact

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Your brit

Just a couple of quick questions. Anything else, we'll talk about on the phone.

Is this brit part of a conversion?
Please choose one
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Have you ever had a circumcision (medical or otherwise)?
Please choose one
What are you looking for?
Hatafas dam bris is a drop of blood taken to complete the covenant when a prior circumcision was done without a brit. A correction is needed when the earlier circumcision was not done fully according to halacha. Not sure? That's fine — we'll figure it out together.
Did someone refer you?

Medical history

The procedure is done under local anesthesia. These questions keep you safe — please answer honestly. If you're not sure about something, say so.

General health

Do you have any current medical conditions?
Please choose one
Please list them
Have you had any significant medical conditions in the past?
Please choose one
Do any of these apply to you?
Check all that apply.
Please check at least one (or "None of these")

Bleeding

Do you or any blood relative have a bleeding or clotting disorder (e.g. hemophilia, von Willebrand)?
Please choose one
Do you bruise easily, or have you bled a lot after a cut, dental work or surgery?
Please choose one
Blood thinners (e.g. warfarin/Coumadin, Eliquis, Xarelto, Plavix)
Please choose one
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Do not stop a prescribed blood thinner on your own. Rabbi Ekstein will coordinate with your doctor.
In the last two weeks have you taken any of these?
These can increase bleeding. Check all that apply.

Medications & allergies

Required — write "None" if none
Have you ever had a bad reaction to a local anesthetic (e.g. at the dentist — lidocaine, Novocain)?
Please choose one
Required — write "None" if none
Are you allergic to latex?
Please choose one

Surgeries & doctors

Are you currently being treated by a doctor for any health issue?

Lifestyle

Do you smoke or vape?
Do you drink alcohol?

Scheduling

Nothing is booked yet — this just helps us plan your call.

When would you like to have the brit?
Please choose one
Where would you like the procedure done?
Usually the procedure is done in a private room at my office, with only me and my assistant present. The brachos are said right after, and family or guests can join for them in the next room.
How would you like to mark the occasion?
Check all that apply. You can change your mind later.
Can someone drive or accompany you home afterwards?
You'll have local anesthesia and should not drive yourself home.
Please choose one
Fee
The usual fee is $1,800–$2,000. If cost is a real obstacle, we can talk privately about a sponsor.

Consent for brit milah

You can sign this now, or wait and sign it in person when we meet, before the procedure. Either way is completely fine.

Consent for Brit Milah
Rabbi Shlome Ekstein, Certified Mohel · 845-467-8595

1. The procedure. I am asking Rabbi Shlome Ekstein to perform a brit milah, hatafas dam bris, or correction of a previous brit, as we discuss and agree. It will take place at the location we agree on, during the day, under local anesthesia. Rabbi Ekstein will explain the main steps, the risks, and the aftercare in English. If English is not my first language, I may ask for a translation (for example, by Google Translate) and ask questions until I understand, before I sign.

2. Who is performing it. I understand that Rabbi Ekstein is a certified mohel with over 15 years of experience. He is not a medical doctor. Another mohel or an assistant may be present to help him.

3. Possible risks. I understand that, as with any procedure, there are risks, including: pain, swelling, or bruising during healing; bleeding, which may need extra care; infection; a reaction to the local anesthetic; a cosmetic result different from what I expected; and in rare cases, the need for further treatment or a doctor's care.

4. Other options. I understand I may choose not to have the procedure, or to have it done by a physician instead.

5. My health information. The information I gave in this form is true and complete to the best of my knowledge. I will tell Rabbi Ekstein about any change in my health before the procedure.

6. Aftercare. I will receive written aftercare instructions and agree to follow them. I will call Rabbi Ekstein with any question, and get emergency medical care right away for bleeding that does not stop with steady pressure, fever, or trouble urinating.

7. Privacy. My information is kept confidential. My forms are seen only by Rabbi Ekstein, unless I agree otherwise or the law requires it. Anyone helping him on the day also keeps everything confidential.

8. My right to change my mind. I may withdraw this consent at any time before the procedure begins. Before we start, Rabbi Ekstein will go over it with me again and answer any questions.

When would you like to sign?
Please choose one
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No problem. We'll go over it together and you'll sign when we meet, before anything begins.

Review & submit

Please check your answers. Tap "Edit" to change any section.

Confirmation

Please confirm
Please confirm
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Thank you

Your intake has been received. Rabbi Ekstein will call you personally, usually within one to two days.

In the meantime, if you have any question at all, call 845-467-8595.