Consent form for the treatment of the tongue tie of the newborn

This consent form must be read and signed before the tongue tie treatment is performed. At Vita Nova you can have the tongue tie cleaved by an experienced midwife. This consent form must be completed before the start of treatment. Treatment: Your child has been diagnosed with a shortened tongue tie. In the folder about cleaving a tongue tie you will find extensive information about what this exactly means. And which various methods can be applied by an midwife, dentist or doctor. The The midwife of Vita Nova who can perform this treatment has completed an additional course for this. She has completed this and performs this action with great regularity. However, this action does not fall under the duties of an midwife. That makes cleaving the tongue tie a reserved act. Payment is made by bank transfer via a payment link. This will be sent after the treatment
Your privacy and your personal data We want to inform you about the processing of your personal data. We store your personal data and medical data digitally. We do this to be able to provide you with good care. We store your data in accordance with our privacy and data security policy. You agree to this by having your care performed by our practice. By signing this form and giving it to us, you indicate that you have taken note of our privacy policy (see and agree to our processing of your (medical) data.
I give permission to Vita Nova midwives to store and share my (medical) personal data with the care providers and authorities mentioned below. We only pass on your data to third parties if this is necessary for the provision of good care. If specific permission is required for this on the basis of the law, we will ask you for this in advance.
We form a digital and written file to process your (medical) personal data. We process your data carefully and no longer than is necessary to provide good care. We adhere to the retention periods of the WGBO.