Tongue Tie Referral | Birthfit Ireland

Name *

Email address *

Phone number *

Baby's Date of Birth and Gestation? *

Baby's birth weight in grams *

Maternal Symptoms *

Nipple Pain
Nipple Trauma
Low Supply
Over Supply
Early Onset/Recurrent Mastitis

Infant Symptoms *

Poor weight gain
Clicking
Excessive dribbling
Lip Blisters
Cannot latch
Cannot maintain latch
Colic
Reflux

Feeding *

Exclusive Breastfeeding
Exclusive Bottle Feeding
Mixed breast and bottle feeding
Other

Did your baby receive Vitamin K? *

Yes, by injection
Yes, oral drops
No.

Known Family history of Bleeding disorder? *

Yes
No
History not known

Is there anything else you want to tell me? *

Tongue Tie Referral Form