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About
Services
Breathing and Airway
Tongue Ties – CO2 Laser
Pediatric Dentistry
Patient/Parent Resources
Blog
Patient Forms
Membership Plans
Make a Payment
Educational Videos
FAQs
Infant Frenectomy
Child Functional Frenuloplasty
Adult Functional Frenuloplasty
Orthodontics FAQ
Appointments
Contact Us
Tanglewood Location
West U Location
Menu
About
Services
Breathing and Airway
Tongue Ties – CO2 Laser
Pediatric Dentistry
Patient/Parent Resources
Blog
Patient Forms
Membership Plans
Make a Payment
Educational Videos
FAQs
Infant Frenectomy
Child Functional Frenuloplasty
Adult Functional Frenuloplasty
Orthodontics FAQ
Appointments
Contact Us
Tanglewood Location
West U Location
About
Services
Breathing and Airway
Tongue Ties – CO2 Laser
Pediatric Dentistry
Patient/Parent Resources
Blog
Patient Forms
Membership Plans
Make a Payment
Educational Videos
FAQs
Infant Frenectomy
Child Functional Frenuloplasty
Adult Functional Frenuloplasty
Orthodontics FAQ
Appointments
Contact Us
Tanglewood Location
West U Location
Menu
About
Services
Breathing and Airway
Tongue Ties – CO2 Laser
Pediatric Dentistry
Patient/Parent Resources
Blog
Patient Forms
Membership Plans
Make a Payment
Educational Videos
FAQs
Infant Frenectomy
Child Functional Frenuloplasty
Adult Functional Frenuloplasty
Orthodontics FAQ
Appointments
Contact Us
Tanglewood Location
West U Location
Make Appointment
(832) 699-7712
Referrals
If you are trying to schedule your infant for a tongue tie consultation, please
call our office
so we can accommodate you ASAP.
Patient Referral Form
First Name
Last Name
Date Of Birth
Parent / Guardian Name
Contact Phone
Contact Email
Reasons for Referral:
Reason for Referral
Restorative Treatment
Frenectomy Consultation
Airway Consultation
Other (Please specify in the comments box)
X-Rays:
X-rays
Sending electronically (please email to info@tanglewood3.wpenginepowered.com)
Patient / parent will bring x-rays
Please take new images
Additional Comments
Submit
