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

Patient Full Name
(must match name on Medicare card)
DD slash MM slash YYYY
Patient Residential Address

MEDICARE

(there are `10 numbers at the top of every Medicare card, enter all numbers)
The number to the left of your name
MM slash DD slash YYYY

YOUR MEDICAL HISTORY

Do you take any medications or supplements?(Required)
For medication - please list name, dosage and when you take your medication.
Your Medical History
Do you child have any of the following medical conditions?
Include Strength and dosage.
(Example - Asthma | Ventoline | 200mg | twice daily)
Procedure Risks
Please read and tick to indicate you understand the risks associated with a Tongue or Lip Tie. If you have concerns regarding risks contact the office immediately and do not complete the form - 07 2103 2322.
Consent / Privacy / Release of information(Required)
This field is for validation purposes and should be left unchanged.
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In an adult with a tongue tie or lip tie may experience neck pain or stiffness, headaches, jaw ache, speech issues.

Queensland Tongue Tie Clinic - Adult Online Registration (15+ Years of Age)

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

Patient Full Name
(must match name on Medicare card)
DD slash MM slash YYYY
Patient Residential Address

MEDICARE

(there are `10 numbers at the top of every Medicare card, enter all numbers)
The number to the left of your name
MM slash DD slash YYYY

YOUR MEDICAL HISTORY

Do you take any medications or supplements?(Required)
For medication - please list name, dosage and when you take your medication.
Your Medical History
Do you child have any of the following medical conditions?
Include Strength and dosage.
(Example - Asthma | Ventoline | 200mg | twice daily)
Procedure Risks
Please read and tick to indicate you understand the risks associated with a Tongue or Lip Tie. If you have concerns regarding risks contact the office immediately and do not complete the form - 07 2103 2322.
Consent / Privacy / Release of information(Required)
This field is for validation purposes and should be left unchanged.