Intake Form

Fill the form below before your tongue tie consultation or print the form by clicking the button below

Click Here For Printable Form

Intake Form

Infant's Name
MM slash DD slash YYYY
MM slash DD slash YYYY
Gender
Birth
Are You Currently Breastfeeding?

Medical History

Did your baby receive a Vitamin K shot?
Was your infant premature?
Does your infant have any heart disease?
Has your infant experienced any of the following?
Has your infant experienced any of the following?
Does mom have any of the following symptoms now or in the past?

woodlands tongue tie center 01

Inside Alden Bridge Pediatric Dentistry.

3759 FM 1488 Suite 125 The Woodlands, TX 77384
Ph: 832 521-9024
kimthekidsdentist@gmail.com