Tongue/Lip Tie Referral Form

Male Female

Thank you for considering our practice for your child's tongue or lip tie procedure. A tongue tie is a common condition that can cause lifelong effects. We provide a full release of the tight tissue using most precise method available and will not put your child to sleep. Please check out our website BridgerChildrensDentistry.com for more information.

Please mark any symptoms below. A tongue tie can cause any combination of the symptoms. The more issues the more likely a restriction is present.

Painful nursing or shallow latch Flattened, bleeding, or lipstick-shaped nipples Difficulty bottle-feeding Slow or poor weight gain Reflux or spitting up often Excessive gassiness or fussiness Prolonged feeding time at the breast or bottle Frustration when eating Milk dribbles out of the mouth while eating Clicking or smacking noise when eating
Clicking or smacking noise when eating Speech delay Slow eater or trouble finishing a meal Picky with textures (e.g. meat, mashed potatoes) Choking or gagging on liquids or foods Restless sleep (kicking or moving while asleep) Grinding teeth at night Sleeps with mouth open Snores (quiet or loud) Frequent headaches or neck pain

Tongue Evaluation Exam

Less than 25% 25-50% 50-75% More than 75%