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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Referral From (Name of Referring Practitioner) *
Phone Number or Email *
Reason for Referral (please describe below) *
Reason for Referral/Concerns - please include information of current concerns *
Patient First and Last Name *
Patient Date of Birth  *
Parent/Guardian First and Last Name *
Parent/Guardian Contact Information (best number to reach them at) *
Parent Email *
Address *
Has the child had a previous release of the tongue? *
Has the child seen any other health care professionals? (Lactation consultant, Speech Therapist, Myofunctional Therapist, Sleep Specialist)?
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