Before an appointment for an evaluation and revision can be made, the form below must be completed and returned with the best possible pictures of the lip reflected back and under the tongue.
The intake form is to help assist in making an active file at our office and keep track of patients needing an appointment. The second page of the form is to help gather current nursing information and challenges for the mother and the child. Please try your best to answer the questions, but if you do not fully understand the questions only answer the questions you understand. This form will need to be returned with the requested pictures prior to setting up an appointment as well. Please ensure you have reviewed and understand the insurance and fees section, as well.
Please download and save form before completing. Completing the form in the browser and then saving will delete all information. Please email all forms (3 pages in total) and pictures to: firstname.lastname@example.org
This can be tricky. The pictures below are good examples of pictures of a tongue and lip tie. Your child’s will not necessarily appear the same way and that does not mean there is or is not an issue. Appearance is part of the puzzle, function is a bigger part of the puzzle of figuring out if a tongue or lip frenulum is causing issues.
You will need 2 adults when taking these pictures. Lay your child down or swaddle them and place both index fingers under the tongue and gently guide it upwards. Have another person take the picture from the angle depicted below. For the lip, take both thumbs and gently roll the upper lip towards the nostrils or gently grasp the upper lip and reflect it up and towards the nostrils. For the tongue, lay the child down and gently guide both index fingers under the tongue and angle them towards the middle of the tongue where the frenulum is located. You will likely need to stabilize your thumbs under the child’s chin and gently elevate the tongue with the index fingers. Do your best, they can be tricky.
If you are seeing your lactation consultant in the very near future, they may be able to help you take the pictures because they are more accustomed to have their hands in an infant’s mouth.