Consent - Infant Form

Please correct the errors described below.

Informed consent for infant oral surgery

  • Lip-tie release
  • Tongue-tie revision

Please do not nurse your infant prior to today's surgery

Prior to completing any oral care on your infant, we require your consent for treating your child. It is the philosophy of our office to provide children the highest quality of care in a manner which is as pleasant and safe as possible. During treatment on small infants, it may be necessary for your infant to be swaddled or placed in a similar protective appliance to control undesirable movements. In some instances, there may be the need for Dr. Geivelis to numb the surgical area using a small amount of a local anesthetic and to provide adequate visibility and access to the surgical areas using a comfortable mouth prop. Older infants may require some type of oral premedication, which if needed, will be discussed prior to having any child sedated. The purpose of all these procedures are to gain and maintain good oral health, primarily at this age, breastfeeding, reducing maternal discomfort and in many instances future problems that may be associated with lingual and or lip-ties. Dr. Geivelis anticipates good results; however, no guarantees as to the results are given. Laser treatment usually proceeds as planned; however, as in all areas of medicine, results cannot be guaranteed, nor can all consequences be anticipated. Post-surgical discomfort may be minimal or last as long as a week, before our goals are met. Bleeding is always a rare possibility. Not treating existing dental problems in children may result in continuing breastfeeding problems. Successful breastfeeding is our primary goal for today's surgery. Parents and guardians should understand recommended procedures, alternative options and anticipated results. All surgery in this office is completed using appropriate laser technology, which has proven safe for infants as well as all patients. Successful results of this surgery is dependent on parents following carefully all post-operative recommendations for keeping the surgical sites from healing together, seeing their lactation consultant and if indicated a myofunctional or other therapist.


I hereby acknowledge that I have been fully informed as to the treatment considerations. I have read and understand this form. I understand the advantages and disadvantages of treatment as well as alternative means of completing these procedures. I understand that my infant will be treated while I remain in the consultation room. The purpose of the surgery was explained to me through a consultation involving oral discussions and written information. I have been given the opportunity to ask Dr. Geivelis all questions I have about the proposed surgical treatment. All questions and concerns have been discussed. I give my free and voluntary, informed consent for treatment to be completed. By signing this consent, I indicate that I have the legal authority to grant this permission. I also agree to pay all fees and have given Dr. Geivelis complete medical history of my child.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.


During office procedures photographs or videos of interesting cases may be completed. We would like your consent to use these for educational purposes such as lectures or professional articles to advance breastfeeding.

I consent to use photos: & videos

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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