QTTC-ADULT - Circumcision Brisbane

15+ YEARS OF AGE - TEEN TO ADULT TONGUE & LIP TIE REGISTRATION

Thank you for completing the online registration with Queensland Tongue Tie Clinic.

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15+ YEARS OF AGE - TONGUE/ LIP TIE REGISTRATION FORM

Patient Name*

First Last

Patient Date of Birth ddmmyyyy*

Patient Residential Address*

Street Address City State / Province / Region ZIP / Postal Code

MEDICARE DETAILS

Patient Medicare Card Number*

Patient Medicare Reference Number*

Expiry Date mm/yyyy*

CLINICAL INFORMATION / REASON FOR REFERRAL

Who diagnosed the Tongue / Lip Tie?*

Dentist

Orofacial Myofunctional Therapist

Chiropractor

Self

Procedure Risks*

Significant post-operative bleeding

More serious complications including death

Tightness or painful scar at the incision site post-operatively, which many be

Efficacy - no clinica benefit from the procedure

Breathing difficulties

Division of the salivary ducts Lingual (tongue) paraesthesia

Infection requiring antibiotics

Sub-optimal cosmetic outcome

Risk of local anaesthetic–fitting, coma, respiratory depression,

Cardiac Arrhythmia and death

Re-attachment – and possibly a second procedure

Sub-Lingual bruising

Lingual (tongue) paraesthesia

Submandibular swelling

PROCEDURE RISKS & CONSENT

It is imperative that we have the correct consents on file.Please carefully read and complete each section. Failure to notify may require in your appointment being rescheduled

RISKS, CONSENT, PRIVACY / RELEASE OF INFORMATION*

Disclosure to others involved in your child's healthcare including referrals to other health practitioners

Sending SMS reminders

Third Choice

Sending email communication

Contacting you and leaving voicemail

AFTERCARE INSTRUCTIONS VIA QR CODE

It is very important to follow the aftercare instructions, post surgery. Aftercare instructions are included in the appointment email sent when you scheduled your appointment and will be made available to you upon successful completion of this form via a QR Code.

I am aware and I have downloaded the aftercare instructions to follow after the Tongue / Lip Tie surgery.

I am aware I have to download the aftercare instructions to follow after the Tongue / Lip Tie surgery & will download them when taken to the QR code

Patient Signature*

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