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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
Thank you for your patient referral submission! Our team will be reaching out to your patient shortly.
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
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