Infant Intake/Consent Form

Financial Policy for Out-of-Network Providers

We request payment for your estimated portion at the time of service. After receiving payment from insurance, you are responsible for the remaining balance. We attempt to provide the most accurate information available regarding your insurance. You should also verify and be knowledgeable about your insurance benefits. Information given to you by us is according to what we have received from your insurance, it is not a guarantee of payment and you will be responsible for any discrepancies. We will always do everything in our power to bill/obtain payment from your insurance, however, your insurance coverage is a contract between you, your employer, and your insurance company and we are not a party to such a contract. Statement of Understanding I have read and understand this information and hereby assign Family Dental Center, Dr. Scott Gardner, DDS. benefits and authorize said assignee to release all information necessary to secure payment. This assignment will remain in effect until revoked by me in writing. A photocopy of the assignment is to be considered as valid

I agree and accept the above policy and will abide by such, all my questions regarding this policy have been

PROCEDURE

Addressing frenums is simple in children less than 9 months old. Older children can could require the use of anesthesia and may be referred to a specialist. The procedure itself takes less than a minute each frenum. Dr. Gardner uses a laser that revises and seals the tissues resulting in very little to no bleeding. The laser procedure is a preferred method of treatment. We expect the baby to able to nurse immediately after the procedure. The baby is swaddled and placed in our dental chair while being stabilized by an adult to minimize movement during the procedure. Then the laser procedure is completed. The baby is returned to mom and given the opportunity to nurse. Babies may cry duringthe procedure, not because they are in pain, but because they are being wrapped up and they may not appreciate something is in their mouth that is not food.

ALTERNATIVE TREATMENTS

The alternative to laser treatment includes scalpel surgery using local anesthesia and/or sedation. The other alternative is to do no treatment. No treatment could result in a number of symptoms including difficulty breast feed, speech development, and swallowing issues. Advantages (benefits) of laser vs. scalpel or scissors include lower probability of re-healing, less bleeding, no sutures (stitches) or having to remove sutures. Disadvantages (risks) are included in the "Risks of Procedure" below.

POST OP INSTRUCTIONS

Following the procedure, the baby may be fussy and may not nurse much at first. Some swelling and/or a fever may occur during the first 24 hours but then should go down. Children's Tylenol can be administered in a dosage recommended by your pediatrician or lactation consultant. Keeping the lip and tongue mobile is important during the healing time. When nursing make sure to flange the upper lip up and over the breast to stretch the area and lift the tongue with a tongue depressor or your fingers to keep the tongue mobile.

Doctor will go over postoperative care and we will email a postoperative video that will give you the information you need following the appointment. A white patch around the lasered area is normal and this is the clotting material in the mouth. Keep the area stretched and mobile until all the white is replaced by pink tissue.

RISKS OF PROCEDURE

While the majority of patients have an uneventful surgery/procedure and recovery, in extremely rare cases complications may occur. Some complications, may include: Bleeding. This may occur either at the time of the procedure or in the first 2 weeks after. Infection. Pain. Damage to sublingual gland, which sits below the tongue. Injury to the teeth, lip, gums, or tongue. The frenum can heal back and require a revision at no charge. Swelling and inflammation, especially of upper lip. Scarring is rare but possible. Eye protection is provided during procedure to prevent damage to eyes.

PARENT CONSENT

I acknowledge that Dr. Scott Gardner has explained my child's condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to my child and the likely outcomes. I was able to ask questions and raise concerns with the doctor about my child's condition, the procedure and its risks, and treatment options. My questions and concerns have been discussed and answered to my satisfaction. I understand and give my permission to have photographs taken during my child's procedure and these photos will be shared with your lactation specialist and available to me at my request. I understand that no guarantee has been made that the procedure will improve the condition. On the basis of the above statements, I REQUEST THAT MY CHILD HAS THE PROCEDURE.