Lingual Frenotomy Referral Form Referral form for Tongue Tie Clinic. Step 1 of 5 20% 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.ReferralPlease add your information.Referring Health Care Professional*IBCLCGPGP Name* First Last GP Phone*GP Email* Lactation consultant (IBCLC)If any.IBCLC Name* First Last IBCLC Phone*IBCLC Email* Date of referral* Date Format: DD slash MM slash YYYY Infant InformationPlease add the infant (patient) information.Infant Name* First Last Infant Gender*MaleFemaleInfant Date of Birth*Add the infant's date of birth. Date Format: DD slash MM slash YYYY Infant Place of birth*Birth Weight*Add the infant's birth weight in kgs.Please enter a number from 1.0 to 7.00.Current Weight*Add the infant's current weight in kgs.Please enter a number from 1.0 to 15.00. Parent InformationPlease add the parent information.Parent Name* First Last Parent Phone Number*Parent Email Parent Address* Street Address City County / State / Region ZIP / Postal Code Reason for ReferralPlease select the reason(s) for the referral.Maternal issuesPlease choose all that apply. Nipple pain Ulceration Mastitis (current or previous) Poor supply Infant issuesPlease choose all that apply. Poor weight gain Can’t latch Can’t maintain latch Aerophagia Colic/Reflux Speech FeedingPlease choose all that apply. Exclusive BF Expressing/Pumping Using nipple shields Supplementation with formula Percentage of feeds non-BF Exclusive formula feeding Percentage of feeds non-BF*(Approx.)Please enter a number from 1 to 100.Tongue functionality/restrictionPlease choose all that apply. Extension Lateralisation Elevation Oral anatomyPlease choose one.NormalAbnormality detectedAnkyloglossiaPlease choose one.AnteriorPosteriorVitamin KPlease choose one.YesNoBleeding/ClottingFamily history of hereditary bleeding/clotting disorder?YesNo Personal informationWe will only use this information for the purposes of communicating with the patient regarding their appointment. Additional CommentsAdd any additional comments (optional).Personal Information*The patient has agreed to their personal information being shared for appointment purposes. I confirmEmailThis field is for validation purposes and should be left unchanged.
