Patient Referral Form

Please complete the form below.

Patient First Name

Patient Last Name

Phone

Contact Email

Date of Birth * required

Referring Partner Name

Is Patient a minor? *

No

Yes

Parent or Guardian Name

Please evaluate for the following * Required

Tongue Thrust Swallow

Tongue Tie / Restricted lingual frenum

Pre / Post frenuloplasty care

Open mouth posture

Mouth breathing

TMD

Thumb or digit sucking habit

Other

Comments

Initials

Thanks for submitting!

This referral form is intended for the secure submission of information necessary to coordinate care. Please submit only information relevant to the referral.

Office: 2685 N. 1000 W. Ste 104 - Pleasant View, UT 84414

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