0 - 14 YEARS OF AGE - CHILD TONGUE & LIP TIE REGISTRATION

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

"*" indicates required fields

This field is for validation purposes and should be left unchanged.
Patient Name
Patient Residential Address*

Section Break

PARENT (A.) INFORMATION

Parent (A.) Name*

PARENT (B.) INFORMATION

Parent (B.) Details Name
Please enter the full details of Parent A as we require this for Medicare claiming reasons

FAMILY MEDICARE DETAILS

(to the left of name)
Medicare Card Expiry Date Must be month, year. (Example: Jan 2090 is 01/2090)
(to the left of name)
Medicare Card Expiry Date Must be month, year. (Example: Jan 2090 is 01/2090)

PATIENT CLINICAL INFORMATION

Who diagnosed the Tongue / Lip Tie?*

RISKS, PARENTAL CONSENT, COURT ORDERS, BIRTH CERTIFICATE

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

BIRTH CERTIFICATE REQUIREMENTS

How many parents are / will be listed on the birth certifcate
***** PLEASE READ **** If there are 2 parents on the birth certificate WE DO NOT NEED TO SITE IT
Max. file size: 256 MB.
PDF only accepted format

COURT ORDERS

Are there court orders in place? If YES please upload them in PDF format or bring it to the appointment.
Are there court orders in place?
Max. file size: 256 MB.
PDF only accepted format
RISKS, CONSENT, PRIVACY / RELEASE OF INFORMATION
Each parent/legal guardian is required to consent to the consultation and procedure being performed on the patient. If there are 2 parents listed on the birth certificate both are required to provide written consent. If court orders are in place detailing the consent required for any medical treatment please contact our office
Procedure Risks
Please ensure you understand that with any medical procedure, there are potential risks, the risks for a Tongue Tie / Lip Tie / Tongue & Lip Tie are:
AFTERCARE INSTRUCTIONS QR CODE*
It is very important to follow the aftercare instructions for 7 days, 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.
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