TONGUE / LIP TIE - NON ATTENDING PARENTAL CONSENT FORM

TONGUE / LIP TIE - NON ATTENDING PARENTAL CONSENT

For any parent who cannot attend the appointment, they are required to complete the non-attending parental consent form.

If there are court orders in place, please bring with you the appointment for the doctor to sight.

It is important to know details about your child’s medical history, as it forms part of vital records for treatment with Dr David Hunt.

The information you provide is confidential and will be handled per our Privacy Policy. We kindly ask you to complete this form a minimum of 48 hours before your appointment as the information is reviewed by Dr Hunt.

By completing, signing & submitting the form, you are making an informed consent to the procedure being performed on the date of appointment.

If you do not consent to some or all of the sections do not complete or submit the form and contact our office to discuss 07 2103 2322

Please note most sections on this form require an entry, if you do not have the answer please enter n/a for not applicable. If you do not have your Medicare card please enter the number 0 in each cell.

Non Attending Parental Consent - Tongue / Lip Tie

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This field is for validation purposes and should be left unchanged.
You have indicated by completing this form you will not be present on the day of the procedure and you consent for the procedure to be carried out without your presence. You are confirming that you are a legal parent / guardian. If you do not consent to anything on this page do not complete the form and contact our office urgently - 07 2103 2322.

All information provided is confidential and will be handled in accordance with our Privacy Policy. We appreciate your assistance and completing this as soon as possible. In accordance with the Privacy Act (1988), all information collected by Gentle Procedures Clinic Queensland is treated as confidential. To protect your child's privacy Gentle Procedures Clinic Queensland operates in accordance with this act.
Child's Full Name (must match Medicare card name)
First Last
Child's Date of birth
Your Full Name (must match Medicare card name)
First Last
*
- I have carefully considered the risks and benefits of this procedure and have discussed them with our family physician or other healthcare professional prior to seeing Dr David Hunt.
*
- I understand that I am making a consent by proxy for our child for a non-therapeutic procedure. By signing this form, I consent to this procedure as the parent of this child.
Consent*
- I understand that complications after a Tongue / Lip Tie can occur, although the frequency varies with skill and experience of the doctor, and are infrequent in Dr David Hunt's practice.
*
- I have considered the potential medical benefits of a Tongue / Lip Tie and request to proceed despite the associated risks with the procedure.
Consent Questions
If you have any questions or concerns with the above consent section please list your questions here and it will be discussed in your consultation.
COMPLICATIONS MAY INCLUDE:
Please note it is our responsibility to ensure you are aware that there are complications and risks with any medical procedure, you must understand these before the procedure is performed. If there is anything you do not understand please add to the questions section.
*
- Significant post operative bleeding (1/400)
*
- More serious complications including death (1/1,000,000)
*
- Tightness or a painful scar at the incision site post-operatively, which may be long-term
*
- Efficacy – (no clinical benefit from the procedure)
*
- Breathing difficulty
*
- Division of the salivary ducts Lingual (tongue) paraesthesia
*
- Infection requiring antibiotics
*
- Sub-optimal cosmetic outcome (1/500)
*
- Re-attachment – and possibly a second procedure
*
- Submandibular swelling
*
- Sub-Lingual bruising
*
- Risk of local anaesthetic – fitting, coma, respiratory depression, cardiac arrythmias and death (very low risk)
Complication Questions
If you have any questions or concerns with the above complication section please list your questions here and it will be discussed in your consultation.
Please tick the procedure your child is having:*
- Consultation only to diagnose a tongue / lip tie
- Consultation & tongue tie surgery single appointment
- Consultation & lip tie surgery single appointment
Pain Management
Although we use effective local anaesthetic and additionally for some patients (3+ years of age) sedation and Penthrox, we cannot guarantee a painless procedure and your son may experience break through pain.
*
- Yes, I understand my child may experience break through pain.
In accordance with the Privacy Act (1988), all information collected by Gentle Procedures Brisbane is treated as confidential. To protect your privacy Gentle Procedures Brisbane operates in accordance with this act. We may use your information provided for any of the following:
Aftercare Instructions
Would like to receive a copy of the aftercare instructions?*
- Yes
- No
If yes please provide your email address*
Non-Attending Parent's Signature*
Please use your mouse or finger to digitally sign and consent to all items in this questionnaire. Please ensure to sign within the box provided.
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TONGUE / LIP TIE - NON ATTENDING PARENTAL CONSENT

Non Attending Parental Consent - Tongue / Lip Tie

COMPLICATIONS MAY INCLUDE:

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