Consent for Frenectomy
Diagnosis: After a careful oral examination and study of my child’s condition, I have been advised that my child 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 on in life.
Recommended Treatment: In order to treat this condition, it has been recommended that a frenectomy (frenulum removal) procedure may be performed I understand that a local anesthetic will be administered as part of the treatment. This surgical procedure involves the removal of a strip of tissue from the associated area(s) of my mouth.
Expected Benefits: The purpose of the frenectomy is to improve the process of breast feeding and speech or any other issues involved.
Principal Risks and Complications: 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 procedure or from anesthetics.
These complications include, but are not limited to:
(1) Post-surgical infection
(2) Bleeding, swelling, and pain
(3) Allergic reactions
(4) Transient numbness of lips teeth or tongue.
(5) Injury to the base of the tongue or the salivary gland openings below the tongue
(6) Superficial burn caused elsewhere on skin or mucosa by the laser.
Follow-Up Care: The expected course of healing has been explained to me. My baby may experience some pain and discomfort for the next 2-3 days for which 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.
No Warranty or Guarantee: I hereby acknowledge 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 or speech. Due to individual patient differences, however certainty of success cannot be predicted. There is risk of failure, relapse and additional treatment despite the best possible care.
Consent: I have been fully informed of the nature of frenectomy procedure, the risks and benefits of such surgery, the necessity for follow-up. I have had an opportunity to ask any questions I may have in connection with the treatment and to discuss my concerns with the pediatrician. After thorough deliberation, I hereby consent for a frenectomy procedure to be performed on my baby as presented to me during consultation.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT