Patient Referral Form

Please complete the form below.

Patient First Name

Phone

Patient Last Name

Contact Email

Date of Birth

Parent or Guardian Name

Referring Partner Name

Referring Partner Email

Please evaluate for the following

Tongue Thrust Swallow

Tongue Tie / Restricted lingual frenum

Pre / Post frenuloplasty care

Open mouth posture

Mouth breathing

TMD

Clenching / Grinding

Thumb or digit sucking habit

Sleep Apnea/ UARS

Snoring

Other

Comments

Initials

Thanks for submitting!

PO Box 13255 Ogden, UT 84412

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