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

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Tongue/Lip Tie Referral Form

Today's Date

Patient's First & Last Name

Patient Birthdate

Male Female

Parent First & Last Name:

Home Phone

Referring Office

Referring Doctor

Referring Doctor Phone

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.

Mother and 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:

Trouble with speech sounds or mumbling Speech delay Slow eater or trouble finishing a meal Picky with textures (e.g. meat, mashed potatoes) Choking or gagging on liquids or foods Spitting out food or packing food in cheeks Restless sleep (kicking or moving while asleep) Grinding teeth at night Sleeps with mouth open Snores (quiet or loud) Frequent headaches or neck pain Mouth breathing during the day

Tongue Evaluation Exam

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

<25% 12-50% 50-75% >75%

Comments:

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

Please send supporting documentation and X-rays to “info@bridgerchildrensdentistry.com”

1039 Stoneridge Drive, Suite 1, Bozeman, MT 59718

Phone: (406) 587-KIDS (5437)

Fax: (406) 577-2172

info@BridgerChildrensDentistry.com

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