Oral Frenulum Release Consent Form

Oral Frenulum Release Consent Form
Please complete this form to provide your informed consent for the oral frenulum (tongue/lip tie) release procedure.
Patient Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name and Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have any known allergies?
If yes, please list your allergies:
Are you currently taking any medications?
If yes, please list your current medications:
Signature of Patient or Legal Guardian
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Date of Consent
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: