You are considering a tongue tie repair procedure on a newborn child whom you are legally responsible for. Complications from tongue tie repair are uncommon, but they do sometimes occur. There is also natural variation from person to person. Because of these facts, there is no guarantee as to the medical result that might be obtained from this procedure.
It is important that you understand this is not considered a medically necessary procedure. This procedure does not guarantee breastfeeding success. As with any surgical procedure, bleeding and infection are possible complications of tongue tie repair procedure. There may not be as much of the lingual frenulum removed as is preferred. There is always a risk of injury to the oral anatomy.
I certify that I have read the contents of this form; I understand the risk involved in this procedure.