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About
Dr Hany
Therapy Dog
Denti-Care Payment Plan
QIP Accreditation
Services
Emergency Dental Service
Lip and Tongue Tie
Frenectomy
How do we Treat Lip & Tongue Tie
Lip Tie Symptoms
What Are The Benefits Of Treatment?
Snipping Vs Laser
Effect Of Not Treating
Craniofacial Therapy
What’s Our Approach
Post-Operative Care Following Frenectomy
Treatment in Mackay QLD
Resources
Pre-Orthodontics
Pre-Orthodontic Appliances
Orthodontics
Clear Aligners
Repairs & Breakages
Orofacial Myology
What Does an OM Program Involve?
Airways and Sleep in Children
Jaw Play for Toddlers
OM and Orthodontics
OM for Adults
OM for Kids
Thumb Sucking Program
Paediatric Dentistry
What makes us different?
Quality Care
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Forms
New Child Patient Form
Expectations After Lip and Tongue Tie
Care for After Lip and Tongue Tie
Health Professional Communication Form
Mackay (07) 4942 5111
Communication Form
Aziz
2022-11-04T05:41:39+10:00
Communication Form
Ensuring the best possible outcomes for our patients
Referrer Details
Referring Clinic
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Practitioner First Name
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Practitioner Surname
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Referring Practitioner Email
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If you are not the above Practitioner please complete your name below.
Other Practitioner First Name
Other Practitioner Surname Name
Patient Details
Child's First Name
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Child's Last Name
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Child's Date Of Birth
Month
Day
Year
Parent First Name
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Parent Surname
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Mobile
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Email
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Degree of Urgency
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High
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Symptoms
Unsettled Baby
Yes
No
Incorrect Swallow Pattern
Yes
No
Learning Difficulties
Yes
No
Colic Symptoms
Yes
No
Incorrect Chewing Patterns
Yes
No
Narrow Upper Arch
Yes
No
Communication Difficulties
Yes
No
Poor Lip Competence
Yes
No
Cross Bite
Yes
No
Feeding Swallowing Difficulties
Yes
No
Bedwetting
Yes
No
Crowded Teeth
Yes
No
Mouth Breathing
Yes
No
Low Tone
Yes
No
Difficulty with Breast Feeding
Yes
No
Snoring
Yes
No
Poor Head Control
Yes
No
Traumatic/Complications During Birth
Yes
No
TMJ Dysfunction
Yes
No
Poor Posture
Yes
No
Tongue thrust
Yes
No
Thumb/Finger/Dummy Sucking Habits
Yes
No
Incorrect Tongue Resting Position
Yes
No
Family History
Family History
Pre-Treatment Recommendation:
Lactation Consultant Date
MM slash DD slash YYYY
Started OM Exercises Date
MM slash DD slash YYYY
Paediatric Chiropractor Date
MM slash DD slash YYYY
3 week Review Date
MM slash DD slash YYYY
Speech Pathologist Date
MM slash DD slash YYYY
Dentist Date of Release
MM slash DD slash YYYY
Referring Practitioner Comments
Referring Practitioner Comments
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