Frenotomy/Frenectomy Intake Form

 

 

GENERAL INFORMATION

 

 


 

 

PAST MEDICAL HISTORY

 

Please Check All That Apply:

 

 

 


 

 

BABY's SYMPTOMS (CHECK ALL THAT APPLY)

 

 


 

 

MOTHER'S SYMPTOMS (CHECK ALL THAT APPLY)

 

 


 

 

HAS YOUR BABY HAD ANY OF THE FOLLOWING?

 

 


 

 

FAMILY HISTORY