Get the free Tongue Tie Referral Form PDF

Southampton Childrens Hospital Tongue Tie Clinic Referral Form Mothers Name: ___Babys name: ___DOB: ___ / ___ / ___DOB : ___ / ___ / ___Phone (home): ___NHS No. ___Phone (mobile): ___Any postnatal

How to fill out tongue tie referral form

How to fill out tongue tie referral form

1. To fill out a tongue tie referral form, follow these steps:
2. Start by entering the patient's personal information, including their name, date of birth, address, and contact details.
3. Provide details about the patient's medical history, including any previous diagnoses or treatments related to tongue tie.
4. Describe the patient's current symptoms or concerns regarding tongue tie, including difficulty with breastfeeding or speech.
5. Include any relevant medical or dental records, such as previous imaging or test results related to tongue tie.
6. If applicable, provide information about the patient's insurance coverage or payment preferences.
7. Sign and date the form to authorize the referral and ensure its validity.
8. Submit the completed form to the appropriate healthcare provider or referral coordinator.

Who needs tongue tie referral form?

1. Anyone who suspects that they or their child may have a tongue tie and requires further evaluation or treatment can benefit from a tongue tie referral form.
2. Common individuals who may need the form include parents of infants struggling with breastfeeding, children experiencing speech difficulties, or adults facing challenges with oral function.
3. Medical professionals, such as pediatricians, lactation consultants, speech therapists, or dentists, may also need the form to refer patients for specialized care.
4. The tongue tie referral form serves as a crucial tool for connecting patients with the appropriate healthcare providers who can assess and address their tongue tie concerns.

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What is tongue tie referral form?

The tongue tie referral form is a document used to refer patients, typically infants or young children, who are suspected of having a condition known as tongue tie (ankyloglossia), which can affect breastfeeding and oral development.

Who is required to file tongue tie referral form?

Healthcare professionals, such as pediatricians, lactation consultants, or dentists, are typically required to file the tongue tie referral form when they identify a potential case of tongue tie that may require further evaluation or treatment.

How to fill out tongue tie referral form?

To fill out the tongue tie referral form, the clinician must provide patient information, details of the assessment, specific reasons for the referral, and any recommendations for treatment or follow-up.

What is the purpose of tongue tie referral form?

The purpose of the tongue tie referral form is to facilitate the communication between healthcare providers regarding the identification and management of tongue tie, ensuring that patients receive appropriate care in a timely manner.

What information must be reported on tongue tie referral form?

The tongue tie referral form must report information including the patient's personal details, medical history, symptoms observed, assessments performed, and specific reasons for referral.