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The Dental Suite

State-of-the-art family dental practice in Bray, Co. Wicklow

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Lingual Frenotomy Referral Form

Referral form for Tongue Tie Clinic.

Step 1 of 5

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  • Dear Healthcare Professional,

    By completing this form you will be sharing the personal data of a mother and child with us. We would ask you to be sure that you have informed them of this and we for our part will be informing them of how we will be handling their data by email before they visit us.

    Please note surgical intervention is only provided when there are established or predicted functional impacts of ankyloglossia.

  • Referral

    Please add your information.
  • If any.
  • Date Format: DD slash MM slash YYYY
  • Infant Information

    Please add the infant (patient) information.
  • Add the infant's date of birth.
    Date Format: DD slash MM slash YYYY
  • Add the infant's birth weight in kgs.
    Please enter a number from 1.0 to 7.00.
  • Add the infant's current weight in kgs.
    Please enter a number from 1.0 to 15.00.
  • Parent Information

    Please add the parent information.
  • Reason for Referral

    Please select the reason(s) for the referral.
  • Please choose all that apply.
  • Please choose all that apply.
  • Please choose all that apply.
  • (Approx.)
    Please enter a number from 1 to 100.
  • Please choose all that apply.
  • Please choose one.
  • Please choose one.
  • Please choose one.
  • Family history of hereditary bleeding/clotting disorder?
  • Personal information

    We will only use this information for the purposes of communicating with the patient regarding their appointment.
  • Add any additional comments (optional).
  • The patient has agreed to their personal information being shared for appointment purposes.
  • This field is for validation purposes and should be left unchanged.

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Contact Us

The Dental Suite
Strand Road, Seafront
Bray, Co. Wicklow

Tel: (01) 202-2809
Emergency Tel: (087) 3130-999
Email: info@thedentalsuite.ie

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