Tongue Tie Referral Form

Parent's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Baby's Name *

First Name

Last Name

Baby's Date of Birth *

MM

DD

YYYY

Maternal Symptoms

Nipple Pain

Nipple Trauma

Early Onset or Recurrent Mastitis

Low Supply

Over Supply

Infant Symptoms

Cannot latch

Cannot maintain latch (slipping)

Clicking

Excessive lip blisters

Aerophagia (gassy)

Reflux

Colic

Poor weight gain

Feeding method *

Exclusive breastfeeding

Exclusive bottle feeding

Mixed breast and bottle feeding

Other (cup, finger feeding, etc...)

Additional information

Pumping/expressing

Using nipple shields

Did your baby receive Vitamin K

Yes, injection

Yes, oral drops

No, we declined

Family history of any bleeding disorder *

Yes

No

Family history not known

Referral pathway *

Lactation Consultant (IBCLC)

Breastfeeding Counsellor

GP

Midwife

Public Health Nurse

Self referral