Love2Latch Covid-19 Consent Form
I, Jas Jones, am a registered Midwife (NMC Registration No: 07B0590E), Tongue Tie Practitioner and International Board-Certified Lactation Consultant (IBCLC).
By completing the Consent form online and signing it, states that you understand the risks and therefore give your Full informed Consent for me to physically assess your baby and perform a frenulotomy (if clinically required).
Practitioner Risk Assessment
At this moment, I am not exhibiting any symptoms of COVID19 infection and I am testing my temperature on a daily basis to catch any fever symptoms early.
I will be washing my hands, as per the PHE recommendation, between every patient, and at least once an hour otherwise whilst in clinic. Hand sanitiser is available for everyone’s use. All sections of the change station, and all seating are cleaned between every patient with Clinnell disinfectant wipes. All hard surfaces are sprayed with disinfectant between every patient.
Patient and practitioner chairs have been placed at least 1m apart from each other. The exception to this is during the point of Oral Assessment and Frenulotomy, where I will be wearing full PPE as recommended by PHE to prevent COVID-19 transmission and the face-to-face appointment will be concise and any follow up care can be provided via telephone/online support.
Those in a high risk demographic (aged over 70, pregnant, or immune compromised) or who have displayed ANY symptoms and have not completed their self-isolation as required (or are still experiencing symptoms), are NOT to attend clinic appointments with client’s for face-to-face care but to instead arrange a video consultation.
Client’s Parent’s Statement
This virus appears to be spreading easily and is thought to spread mainly from person-to person through people who are in close contact with one another through respiratory droplets produced when an infected person coughs or sneezes. Whilst it is currently thought that people are most contagious when they are most symptomatic, it is possible some spread might be possible before people show symptoms.
Ultimately, I understand that Jas Jones at Love2Latch, is doing all that is reasonably possible to minimise risk whilst providing an essential service for me and my baby. However, I understand that she cannot eliminate risk, especially as COVID-19 can be spread by those showing no symptoms.
I understand that there is a risk of transmission of COVID-19 as a result of attending the clinic I agree that Jas Jones of Love2Latch, cannot accept responsibility for transmission of COVID-19 should I or my baby become infected in the future.
I have completed the Online Medical Questionnaire, Consent Form and Covid-19 Screening Form and the information is true and accurate to the best of my knowledge.
I have informed Jas about the following points online or over the phone and can confirm:
- As already stated, I confirm we have no family history of bleeding conditions
- I confirm that my baby has no other known medical conditions or is under the care of a paediatrician
- I confirm that my baby has had vitamin K at birth (if declined, to be discussed prior to the consultation.
If there is any issues regarding the above 3 points, I can confirm that I have disclosed this accurately and honestly directly to Jas prior to our appointment.
I confirm that I have a clear understanding of the process involved with the procedure and I am aware of the following also:
- I confirm that I understand my baby may be unsettled or fussy for a few days following the procedure
- I confirm that I understand that the risk of excessive bleeding is a rare complication (1:400 requiring pressure, 1:7000 requiring adrenaline in hospital, 1:77000 requiring suturing/cautery ATP 2018). However, although rare, I understand that if required, Ambulance attendance and transfer to hospital may be delayed during this pandemic
- I confirm that I understand that during COVID-19, we have no evidence base to suggest that the risk of bacterial infection in babies post division is affected by the presence of the virus, however this is not to say that it may not be relevant.
- I confirm that I understand that damage to any surrounding structures is possible but an extremely rare risk.
- I confirm that I understand that it may take a period of a few days or weeks for the healing process to be complete and feeding to become completely comfortable, I will refer to the ATP care after division leaflet for information.
- I confirm that I understand that in 3% of cases, residual frenulum may remain or reattach, and a further procedure may be necessary to achieve further improvement (ATP, 2017).
- I confirm that I understand that undergoing a frenulotomy, may not improve feeding completely.