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Patient Name

Are there any known bleeding problems that run in the family such as hemophilia, Von Willebrand disease, etc?*
Vitamin K injection is a standard medication given after birth to help prevent hemorrhagic disease of the newborn. Did your child receive Vitamin K injection after birth?*
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Additional Risk Acknowledgment*
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Procedure Consent*
I understand that the purpose of a frenectomy is to improve the process of breast feeding.

After a careful oral examination and study of the patient’s condition by a physician, I have been advised that the patient has a frenulum attachment problem which may be affecting the process of breast feeding. In some cases, a frenulum may interfere with speech, appearance or function later in the patient’s life. In order to treat this condition, it has been recommended that a frenectomy (frenulum removal) be performed. This surgical procedure involves the removal of a strip of tissue from the associated area(s) of my mouth.

I understand that some patients do not respond successfully to frenectomy procedure. In some cases, the attempt to remove the frenulum may not be completely successful or the frenulum may reattach. In these cases, the procedure may need to be repeated.

I understand that complications may result from a frenectomy. These complications include, but are not limited to: post-surgical infection; bleeding, swelling, and pain; allergic reactions; transient numbness of lips, teeth or tongue; injury to the base of the tongue or the salivary gland openings below the tongue; superficial burn caused elsewhere on skin or mucosa by the cautrey.

I understand that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. In most cases, the treatment should provide benefit in the process of breast feeding. Due to individual patient differences, certainty of success cannot be predicted. There is risk of failure, relapse and additional treatment despite the best possible care.

I understand that if complications occur, the patient may need to undergo additional medical procedures and/or be taken to a hospital for continued care. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to the physician to perform such procedures at his or her discretion if needed during the procedure.

I understand the expected course of healing. The patient may experience some pain and discomfort for the next 2-3 days. Tylenol may be given. During the healing process, an adherent whitish film may form at the site of the tongue tie. This is normal and indicates healing. The site may look discolored for the next couple of days.

I, (parent or legal guardian) acknowledge, with my signature, that a physician has discussed the above information with me. I’ve had the opportunity to ask questions. All of my questions have been answered to my satisfaction and I do hereby agree and consent for the patient to undergo a frenectomy.

Financial Responsibility*
I understand that my insurance company may refuse to pay for this service. I also understand that some or all of the charges may go toward my deductible. If this occurs, I understand that I am required and agree to pay, in full, any amount not covered by my insurance company.
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Parent or Legal Guardian Name*
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