Un•tied Registration Form

This is the registration form for working with Dr. Bower at Untied for Lip and Tongue Release. Blossom will be working with Dr. Bower to ensure your information is transferred successfully and safely for your consult. You should be contacted within 2-3 business days.

If you do not hear from our staff at Blossom after 2-3 business days, please contact the office at (602) 256-7766 or email through our contact form.

To receive the best care possible, please complete this form in its entirety.

*Required Fields

Mother's Information:

Infant's Information:

Contact Information:

Insurance Information:

Additional Notes and Questions

Please provide any additional questions or requests regarding your verification below:

Dental Insurance Policy

If you have a dental policy please complete the section below: