NON ATTENDING PARENTAL CONSENT – Queensland Tongue Tie Clinic

Date you completed the non-attending parental consent(Required)

Child's Full Name (must match Medicare)(Required)

Child's Date of Birth(Required)

Your Full Name(Required)

Your Date of Birth(Required)

COMPLICATIONS MAY INCLUDE(Required)

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.

Pain Management

Yes. I have read and understand - although we use effective local anaesthetic we cannot guarantee a painless procedure and your child may experience break through pain.

PARENT CONSENT(Required)

I understand that I am making a consent by proxy for my child to have a non-therapeutic procedure.

I have considered the potential medical benefits of tongue/lip tie surgery and request to proceed despite the associated risks with the procedure.

I understand that complications after a tongue or 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 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.

By signing this form, I consent to this procedure as the parent of this child.

Would you like a copy of the aftercare instructions?(Required)

Yes please

No thank you

If Yes, what is your email address to send the aftercare instructions to?

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Non-Attending Parental Consent Form

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