Get the free Lip-Tongue-Tie-Referral-Form

Paul Kahlo, DMD, FRED Diplomat: American Board of Pediatric Dentistry International Affiliation of Tongue tie Professionals www.stellarkids.com l email: hello@stellarkids.com Mill Creek Fax: 425.948.6484

How to fill out lip-tongue-tie-referral-form

How to fill out lip-tongue-tie-referral-form

1. To fill out the lip-tongue-tie-referral-form, follow these steps:
2. Obtain the form: You can request the form from your healthcare provider or download it from an appropriate website.
3. Begin with your personal information: Fill in your name, date of birth, address, phone number, and email address.
4. Provide patient details: Enter the patient's name, date of birth, and any relevant medical history.
5. Specify the reason for referral: Indicate whether it is for a lip tie or a tongue tie and provide a brief explanation.
6. Include any additional information: If there are any specific concerns or symptoms, make sure to mention them in detail.
7. Obtain the healthcare provider's information: Enter the name, address, phone number, and fax number of the referring healthcare provider.
8. Sign and date the form: At the end of the form, sign and date it to complete the referral process.
9. Submit the form: Depending on the instructions provided, either send the form via fax, email, or personally deliver it to the designated recipient.
10. Make sure to review the filled form for accuracy and completeness before submitting it.

Who needs lip-tongue-tie-referral-form?

1. The lip-tongue-tie-referral-form is needed by individuals who suspect that they or their child have a lip tie or a tongue tie that requires medical evaluation or intervention.
2. This form is typically needed when seeking a consultation or treatment from a specialist, such as a pediatric dentist, oral surgeon, or speech therapist, who specializes in lip and tongue tie issues.
3. It is important for individuals who suspect a lip or tongue tie to complete this form to facilitate the referral process and ensure proper evaluation and treatment.

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What is lip-tongue-tie-referral-form?

The lip-tongue-tie-referral-form is a document used by healthcare providers to refer patients who may be experiencing issues related to lip or tongue ties, which can affect feeding, speech, and oral development.

Who is required to file lip-tongue-tie-referral-form?

Healthcare providers such as pediatricians, dentists, or lactation consultants who identify a potential lip or tongue tie in a patient are required to file the lip-tongue-tie-referral-form.

How to fill out lip-tongue-tie-referral-form?

To fill out the form, providers should include patient information, details of the observed lip or tongue tie, relevant medical history, and any necessary assessments or evaluations performed.

What is the purpose of lip-tongue-tie-referral-form?

The purpose of the lip-tongue-tie-referral-form is to streamline the referral process for patients who need further evaluation and treatment for lip or tongue ties, ensuring appropriate care is provided in a timely manner.

What information must be reported on lip-tongue-tie-referral-form?

The form must report the patient's name, date of birth, contact information, the nature of the lip or tongue tie, any associated symptoms, past treatments, and the referring provider's details.