Visit Tongue-Tie & Airway Center

Referral Forms

Fill out the below form to refer a patient to our practice for laser tongue-tie release or other pediatric dental care. Our pediatric dentists in Okemos, MI, proudly serve patients and their families.

Need to refer someone to us?

"*" indicates required fields

Date of Referral*

Patient Name*

Patient Date of Birth*

Parent Name*

Phone #*

Insurance Carrier*

Healthy kids dental accepted for patients under 5 (on a referral basis only).

Group or Subscriber ID*

Please Evaluate For*

Dental Caries/Cavities

Space maintenance concerns

Tongue/Lip-Tie Evaluation

Sleep Disordered Breathing

Sedation/General anesthesia

Trauma/Emergency

Anxiety

Please have legal guardian contact our office at their earliest convenience to obtain an appointment. *First appointment is for consultation only. Please bring a copy of your current dental insurance card and ID. All patients must be accompanied by a legal guardian.

Comments*

Send all Radiographs to: office@mydiscoversmiles.com

Referring Provider*

Provider Email*

Provider Phone #*

Provider Address*

Street Address City State

This field is for validation purposes and should be left unchanged.

85586

Menu

Referral Forms

Need to refer someone to us?

Send all Radiographs to: office@mydiscoversmiles.com

About Our Practice

Pay My Bill

Pediatric Services

Parent Resources

Get In Touch

Menu

Referral Forms

Need to refer someone to us?

Send all Radiographs to: office@mydiscoversmiles.com

Follow us on