Please complete this form (2 pages) and send by secure (NHS) email to: (preferred option). Alternatively fax to: 0208 394 3863 PLEASE OBSERVE THE REFERRAL CRITERIA The service is for babies over 11 days of age and registered with a Surrey GP. Please note that babies registered with a Surrey Downs CCG GP can be seen at a younger age. This service is a frenulotomy service for babies who are identified with a tongue tie after 11 days of age and whose tongue tie is interfering with the baby’s ability to breast feed. The service is aimed primarily at babies for whom breastfeeding is the method of choice. If there are parental concerns regarding the impact of a tongue-tie on future speech, dentition or the introduction of solid foods, advice should be sought from the General Practitioner to discuss a hospital referral. Area referred from: CSH Surrey / First Community Health / Virgin Care Baby’s name: Date of Place of birth: Address: Tel Home: Tel Mobile: NHS number: General Practitioner & Surgery: Name of referrer: Designation Email address: Phone no: Name of Infant Feeding Lead: (If known) 1 Referrer should take a full history and observe a feed
Please complete this form (2 pages) and send by secure (NHS) email to: (preferred option). Alternatively fax to: 0208 394 3863 PLEASE OBSERVE THE REFERRAL CRITERIA The service is for babies over 11 days of age and registered with a Surrey GP. Please note that babies registered with a Surrey Downs CCG GP can be seen at a younger age. This service is a frenulotomy service for babies who are identified with a tongue tie after 11 days of age and whose tongue tie is interfering with the baby’s ability to breast feed. The service is aimed primarily at babies for whom breastfeeding is the method of choice. If there are parental concerns regarding the impact of a tongue-tie on future speech, dentition or the introduction of solid foods, advice should be sought from the General Practitioner to discuss a hospital referral. Area referred from: CSH Surrey / First Community Health / Virgin Care Baby’s name: Date of Place of birth: Address: Tel Home: Tel Mobile: NHS number: General Practitioner & Surgery: Name of referrer: Designation Email address: Phone no: Name of Infant Feeding Lead: (If known) 1 Referrer should take a full history and observe a feed