Click here to submit an online referral
Click here to download a fax-able referral form
Frenectomy/Tongue Tie Referral for Children and Teenagers
Frenectomy/Tongue Tie Referral for Children and Teenagers – Spanish
Infant Frenectomy/Tongue Tie Referral
Infant Frenectomy/Tongue Tie Referral – Spanish
The frenectomy/tongue tie forms are designed to be filled out BY THE PARENT. Based on the responses, providers can determine if a referral is recommended. Please feel free to call us if you have questions.
Thank you for your trust and allowing us to be a part of your team. We look forward to working together to achieve optimal oral health for your patient!
There are several components that we investigate to formulate the appropriate, individualized plan for each child. Specifically, we thoroughly assess:
- Medical health of child, including:
- Medical conditions
- Weight/ BMI
- Tonsillar assessment
- Special needs
- Caries Risk (including oral hygiene and dietary habits)
- Growth and Development Patterns
- Extent of treatment needed
- Behavior/ Ability to tolerate treatment needed
- Any other contributing issues (bruxism, oral habits, hypoplastic enamel, etc)
Based on the cumulative findings above, we may propose:
- No treatment/ monitor conditions
- Treatment with nitrous oxide
- Treatment with oral conscious sedation
- Treatment with IV sedation
- Treatment under general anesthesia at Children’s Medical Center of Dallas.
Learn more about our Relaxation Treatments.
Again, we thank you for the privilege of working with your patients!
Please send any X-rays or other pertinent information to firstname.lastname@example.org.