Provider Questionnaire
****WE ARE NOT CURRENTLY REVIEWING NEW SUBMISSIONS****
Name
Your answer
Contact Information
Professional Address, Phone #, Email, Website
Your answer
Do you diagnose and revise “posterior” (submucosal) tongue ties?
Do you diagnose and revise lip ties?
Please could you give a brief summary of your opinion on any impact that tongue and/or lip ties may have on feeding (breastfeeding and otherwise)?
Your answer
Please could you give a brief summary of your opinion on any impact that tongue and/or lip ties may have on speech, dental health and anything else you may like to mention?
Your answer
Are there age limitations in your practice, when it comes to tongue and/or lip tie revision?
Please explain any age limitations in your practice.
Your answer
How many revisions do you do per year in children age one year and under?
Your answer
Do you routinely use any type of sedation when revising tongue and lip ties?
If sedation is not routine, what, if anything, may cause you to use it?
Your answer
Do you routinely place sutures?
If sutures are not routine, what may cause you to use them?
Your answer
Do you revise with laser or scissors?
If laser, what type?
Your answer
Do you use a grooved director to isolate the tongue tie for:
Always
Sometimes
NA
Assessment
Release/Revision
Approximately how long does an average revision take?
Your answer
What do you recommend for aftercare (including wound management)?
Your answer
What arrangements do you have in place to follow up with patients, after the procedure is complete?
Your answer
Do you recommend anything for pain management before, during or after the procedure?
Required
May mothers breastfeed immediately after the procedure?
Do you allow parents in the room during the procedure?
If you do allow parents in the room, how many people may accompany the child?
Your answer
Who holds the child during the procedure?
Required
Will you revise the ties the same day as the consultation?
How long does it typically take to get an appointment with you?
Your answer
Do you have Lactation Consultants who routinely refer to you (or to whom you refer your patients)?
If you do have Lactation Consultants that refer to you or to whom you refer, may we have their information?
Your answer
What are your fees?
Do you charge separate fees for each revision site?
Do you provide a discount for patients paying completely out of pocket?
Do you take insurance?
If you take insurance, which ones?
Your answer
What is your policy if subsequent revision is necessary?
Your answer
Please explain ease of parking, public transportation, hotels, etc. in relation to your office.
Your answer
Please share any additional information about you and your practice, that you feel we should know. Also include any specific info you would like to be included if added to the provider list.
Your answer
Will you be willing to add a link to the Advocates for Tongue-Tie Education (ATTE) site on your clinic or business website?
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