Spot Pal's Leading Provider LISpeech.com

631-675-1254

I consent to the use of a customized tongue training device (the “Device”) similar to a retainer which fits over the teeth and has been modified to contain tongue spikes. A benefit of the Device is that it trains proper tongue resting posture, and dissuades the tongue from thrusting on or between the teeth, further deterring noxious oral habits that interfere with speech. The Device is not FDA-approved. The estimated frequency of treatment is determined by the licensed speech-language pathologist [ i.e. daily]. The Device is to be worn for a duration determine by the treating speech-language pathologist [ i.e. 30 minute periods] and the tongue spikes may cause pain or discomfort to the wearer’s tongue. I understand that there may be unexpected side effects and cannot guarantee that neither these treatments nor the Device will be successful. I understand that although the treatment plan and the Device is anticipated to help me, it may not be effective for this purpose and may not help me. I understand possible sides effects may include, but are not limited to, swelling, dislodgement of tongue spikes, redness, ulceration, bleeding, irritation, pain/discomfort, swallowing of dislodged tongue spikes. By signing below, I acknowledge that I understand the benefits and risks (including, without limitation, the possible side effects listed above) involved and am willing to proceed. I voluntarily and knowingly recognize, accept and assume all risks and dangers and all responsibility for any losses and/or damages associated with this treatment and use of the Device. This consent will remain in effect until it is revoked in writing.