Tongue/Lip Tie Referral Form - Bridger Children's Dentistry

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About
Our Specialties
Resources
- Financing & Insurance
- Patient Education
Forms
Referrals

Tongue/Lip Tie Referral Form

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Today's Date

Patient's First & Last Name *

First

Last

Patient's Birthdate

Patients Gender

Male
Female

Parent's First & Last Name *

First

Last

Home Phone Number

Referring Office

Referring Doctor

Referring Doctor Phone Number

Thank you for considering our practice for your child's tongue or lip tie procedure. A tongue tie is a common condition that can cause lifelong effects. We provide a full release of the tight tissue using most precise method available and will not put your child to sleep. Please check out our website BridgerChildrensDentistry.com for more information.

For any immediate questions please list them here.

Please mark any symptoms below. A tongue tie can cause any combination of the symptoms. The more issues the more likely a restriction is present.

For Referring the

Mother & Baby Symptoms:

Painful nursing or shallow latch
Flattened, bleeding, or lipstick-shaped nipples
Difficulty bottle-feeding
Slow or poor weight gain
Reflux or spitting up often
Excessive gassiness or fussiness
Prolonged feeding time at the breast or bottle
Frustration when eating
Milk dribbles out of the mouth while eating
Clicking or smacking noise when eating

Child Symptoms:

Clicking or smacking noise when eating
Speech delay
Slow eater or trouble finishing a meal
Picky with textures (e.g. meat, mashed potatoes)
Choking or gagging on liquids or foods
Choking or gagging on liquids or foods
Restless sleep (kicking or moving while asleep)
Grinding teeth at night
Sleeps with mouth open
Snores (quiet or loud)
Frequent headaches or neck pain
Frequent headaches or neck pain

Tongue Evaluation Exam

With the mouth open wide, how high does the tongue lift to the palate?

Less than 25%
25-50%
50-75%
More than 75%

Comments:

Please call (406) 587-5437 to schedule a no-obligation consult.

1039 Stoneridge Drive, Suite 1, Bozeman, MT 59718

Phone: (406) 587-KIDS (5437)

Fax: (406) 577-2172

info@BridgerChildrensDentistry.com

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