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Referral Form for Children for Lip/Tongue Ties & Myofunctional Therapy
This form is intended for for children over the age of 1 year being referred for lip/tongue ties or for myofunctional therapy. This form can be filled out by a medical professional or as a self referral by a parent/ guardian or legal representative.
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* Indicates required question
Referral From (Name of Referring Practitioner)
*
Your answer
Phone Number or Email
*
Your answer
Reason for Referral (please describe below)
*
Lip Tie
Tongue Tie
Myofunctional Therapy
Other:
Required
Reason for Referral/Concerns - please include information of current concerns
*
Your answer
Patient First and Last Name
*
Your answer
Patient Date of BirthÂ
*
MM
/
DD
/
YYYY
Parent/Guardian First and Last Name
*
Your answer
Parent/Guardian Contact Information (best number to reach them at)
*
Your answer
Parent Email
*
Your answer
Address
*
Your answer
Has the child had a previous release of the tongue?
*
Yes
No
Has the child seen any other health care professionals? (Lactation consultant, Speech Therapist, Myofunctional Therapist, Sleep Specialist)?
Your answer
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