Forms

Provider Referral Form

Referring Doctor

Patient's Name

Patient's Phone Number

Patient's DOB/Age

Patient’s parent / Guardian Name (if a minor)

Reason for Referral (Required) Please check all that apply * Required

Myofunctional Therapy Evaluation

Pre-Orthodontic Therapy

Tethered Oral Tissues

Open Mouth Posture

Thumb/ Finger Sucking Habit

Oral Appliance Collaboration

Tongue Thrust

Low Resting Tongue Posture

Mouth Breathing

Other

Other, please specify below:

Special Note to Myofunctional Therapist:

Thanks for submitting!

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