Appointments & Enquiries 0409632693
Aftercare Support 0448 792 128
Email Us
HOME
CONTACT US
PRACTICE LOCATIONS
REGISTRATION
CHILD REGISTRATION
NON ATTENDING PARENTAL CONSENT
ADULT TONGUE / LIP TIE REGISTRATION
BOOK ONLINE
COST & MEDICARE
HOME
CONTACT US
PRACTICE LOCATIONS
REGISTRATION
CHILD REGISTRATION
NON ATTENDING PARENTAL CONSENT
ADULT TONGUE / LIP TIE REGISTRATION
BOOK ONLINE
COST & MEDICARE
HOME
CONTACT US
PRACTICE LOCATIONS
REGISTRATION
CHILD REGISTRATION
NON ATTENDING PARENTAL CONSENT
ADULT TONGUE / LIP TIE REGISTRATION
BOOK ONLINE
COST & MEDICARE
HOME
CONTACT US
PRACTICE LOCATIONS
REGISTRATION
CHILD REGISTRATION
NON ATTENDING PARENTAL CONSENT
ADULT TONGUE / LIP TIE REGISTRATION
BOOK ONLINE
COST & MEDICARE
Tongue Tie Quick Contact Form
QUICK CONTACT - TONGUE TIE
Patient Name
(Required)
* Must match name on Medicare card.
First
Middle
Last
Patient date of birth
(Required)
DD slash MM slash YYYY
Patient Phone Number
(Required)
Patient Email Address
(Required)
Who diagnosed the Tongue Tie?
Self
Dentist
Orthodontist
Midwife / Lactation consultant
Speech pathologist
other, please list in comment section below
Comment
INFANT TONGUE TIE
Please enter YES into any of the following issues affecting your child.
Latching issues
Falling sleep when feeding
Not gaining weight
Pain for mother
Other, please list
Fussy
Falling off the breast
Add
Remove
CHILD TO ADULT TONGUE TIE
Please enter YES into any of the following issues affecting the patient.
Gap between the two front teeth
Fussy eater
Other, explain
Add
Remove
Comment
Do you want to book an appointment now?
(Required)
Yes
No
If yes, which location do you want to attend:
(Required)
Spring Hill - M,T,W afternoons 2pm to 6pm
Underwood - Saturday
Toowoomba East - Friday
Further Information / Notes
If there is anything else you believe we need to know please document here.
CAPTCHA
Δ