Tongue-Tie Release Patient Intake Form
Please complete the Tongue-Tie Release Patient Intake Form to help us prepare for your visit.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Referring Provider or Clinic
Primary Reason for Visit
*
Feeding difficulties
Speech concerns
Dental concerns
Other
Current Symptoms
Difficulty latching (breast or bottle)
Poor weight gain
Speech articulation issues
Mouth breathing
Snoring
Clicking sounds while feeding
Other
Feeding Method
Breastfeeding
Bottle feeding
Both
Not applicable
Known Allergies
Previous Treatments for Tongue-Tie
Emergency Contact Name & Phone
*
Submit
Should be Empty: