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About Professor Brice Antao
Clinical Profile
Surgical Expertise
Chest Wall Deformities
Tongue Tie
Laparoscopic Surgery
Robotic Surgery
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Baby's Name
*
Mother's Name
*
Contact Telephone Number
*
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Date of Birth
*
DD
1
2
3
4
5
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11
12
13
14
15
16
17
18
19
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21
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29
30
31
/
MM
1
2
3
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6
7
8
9
10
11
12
/
YYYY
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
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2002
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1953
1952
1951
1950
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1947
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1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Birth Weight
Current Weight
Place of Birth
Maternal Symptoms
Nipple Pain
Ulceration
Mastitis
Poor Supply
Other
Other
Infant Symptons
Poor weight gain
Can't latch
Can't maintain Latch
Aerophagia
Colic/Reflux
Speech
Other
Other
Feeding
Exclusive BF
Expressing
Formula
Combination
Ankyloglossia
Anterior
Posterior
Comment
Comment
Tongue Restriction
Elevation
Lateralisation
Extension
Oral Anatomy
*
Normal
Abnormality detected
Comment
Vitamin K
*
Yes
No
Family History of Clotting disorder/Haemophilia/Von Willebrands etc
*
Yes
No
Referring Practitioner
*
Qualification
IBCLC
GP
Consultant
Public Health Nurse
Midwife
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Home
About Professor Brice Antao
Clinical Profile
Surgical Expertise
Chest Wall Deformities
Tongue Tie
Laparoscopic Surgery
Robotic Surgery
Academic Profile
Original Articles
Published Abstracts
Books & Chapters
Presentations
TONGUE-TIE REFERRAL FORM
Online Referral Form
PDF Referral Form
Contact
Locations
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