Milton Geivelis Referral Form (Frenectomies)

Patient Name

Date

Patient Phone No.

Referring Health Professional

Appointment on

Time

The Area of Major Concern (Please circle all that apply)

Breastfeeding: (Tongue-Tie, Lip-Tie upper, Lip-Tie Lower, Buccal-Tie upper, Buccal-Tie Lower)

Speech Problems: (Tongue-Tie, Lip-Tie upper, Lip-Tie Lower, Buccal-Tie upper, Buccal-Tie Lower)

Sleep Apnea

Other Information: (Gum Recession, Tooth Spacing)

If other, Please specify

Please forward documents and photos to our secure e-mail: info@drmiltongeivelis.net

This Patient is:

New to my Practice

# of years in Recall

Years

I would like Dr.Geivelis to call

I would like Dr. Geivelis to write

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