Please be patient after selecting the submit button.  It may take a several minutes to process your submission depending on the speed of your internet connection.  A note should appear at the top of the page, in place of the form, confirming submission - if not, please contact the office at 636-875-1140.

If you have been referred for a Tongue Tie/Lip Tie Evaluation or Breastfeeding Evaluation, please submit the following form with the Mother and Child information.  You will receive an phone call notifying you that you have been registered as a patient and information about available appointments.


Unfortunately, our website does not function specifically for smartphone and tablet users, if you are having difficulties, please switch to a computer for a more efficient form submission. 


FOR ANDROID USERS:  Please use the DEFAULT, Pre-Installed web browser on your device (not chrome, firefox, explorer ect.)

FOR COMPUTER USERS:  If you are having difficulties please switch to a different web browser, such as Chrome or Internet Explorer.


We have had a great influx of requests recently and are doing our best to adjust our schedules in order to schedule everyone in a timely manner.  At this time, we will be able to contact you within 7 business days after receiving your consultation request form.

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