If not picked up at birth children with significant tongue ties can't start to fall behind their peers because they cannot speak properly.

Queensland Tongue Tie Clinic - Child Online Registration (00 - 15 Years of Age)

It is important to know details about your child's medical history as it forms part of vital medical records. Please complete this form a minimum of 48 hours before appointment. This allows adequate time for the doctor to review these records prior to your appointment. If your child is under the care of a specialist please arrange a referral letter. If you child is taking blood thinners please see your GP and advise you are required to cease them for the procedure. Your GP will need to write a letter outlining medical clearance for the procedure to be carried out. All fields are mandatory, if you do not have the information on hand please enter n/a for not applicable.

Child's Full Name(Required)
(must match name on Medicare card)
DD slash MM slash YYYY
Child's Residential Address

PARENT DETAILS

Parent (A) Full Name(Required)
Must match name on Medicare card.
Parent (B) Full Name
Must match name on Medicare card.
DD slash MM slash YYYY
DD slash MM slash YYYY

BIRTH CERTIFICATE REQUIREMENTS

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 for further instructions 07 2103 2322. Failure to do so may result in the appointment being rescheduled / cancelled.
How many parents are listed on the child's birth certificate(Required)
If (ONE) the doctor must sight it so please bring to the appointment. If you have not received the birth certificate please contact the office for further instruction - 07 2103 2322.

CHILD & PARENT MEDICARE DETAILS

Medicare details are required for each parent and the child.
If you do not have it enter 0000000000
This is the number to the left of your child's name
mm/yyyy
If you do not have it enter 0000000000
All of the numbers across the top of the card
This is the number to the left of your name
mm/yyyy
All of the numbers across the top of the card
Please enter a number from 10 to 10.
This is the number to the left of your name
mm/yyyy

PATIENT MEDICAL HISTORY

If yes please provide their full name and practice name
If yes please provide their full name and practice name.
Does your child take any medications or supplements?(Required)
If yes please list name and dosage
Medical History(Required)
Does your child have any of the medical conditions? If yes please enter the information into the note field
Please provide all medical history, allergies, medication, supplement history

PROCEDURE RISKS

Please read and tick to indicate you have read and understand the risks associated with a Tongue or Lip Tie.
Parent / Legal Guardian (A.) - Procedure Risks(Required)
Parent / Legal Guardian (A.) - Procedure Risks

CONSENT, PRIVACY / RELEASE OF INFORMATION

Parent / Legal Guardian (A.) Consent(Required)
Parent / Legal Guardian (B.) Consent

SECURITY

DD slash MM slash YYYY
Who completed the online registration?(Required)

Looking front on hold the tongue up and take a (1.) photo of the band of skin under the tongue. 2. Turn the head to the RIGHT, hold tongue up and take (1.) photo of the band of skin. 3. Turn the head to the LEFT, hold tongue up and take (1.) photo of the band of skin.
Drop files here or
Accepted file types: jpg, gif, pdf, png, Max. file size: 32 MB, Max. files: 3.

    PARENT / LEGAL GUARDIAN SIGNATURE

    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 for further instructions 07 2103 2322. Failure to do so may result in the appointment being rescheduled / cancelled.
    This field is for validation purposes and should be left unchanged.