Referral Form for TMD / TMJ

SMART
Dr. Shauna Palmer, BSc., DDS, LVIF 2446 Main St., West Kelowna, BC

SAFE MERCURY AMALGAM REMOVAL TECHNIQUE

reception@healthandbeauty.dentis www.drshaunapalmer.ca
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REFERRAL FORM FOR TMD/TMJ/OSA and/or SMART
Date

MonthDayYear
Date
Office Contact #
Referring Health Practitioner: (print name)
Referring Health Practitioner: (signature)

Clear
Patient's Name
Address
Contact #
Contact Email
example@example.com
SYMPTOMS

HeadachesFacial Pain (Nonspecific)Tender, Sensitive Teeth (Percussion)Cervical PainDifficulty ChewingPostural ProblemsTingling of FingertipsThermal Sensitivity (Hot and Cold)Trigeminal NeuralgiaBell's PalsyNervousness / Insomnia
Tender, Sensitive Teeth (Percussion)

TMJ PainTMJ NoiseLimited OpeningVertigo (Dizziness)Tinnitus (Ringing in the Ears)Ear CongestionLoose TeethClenching / BruxingDifficulty SwallowingDifficulty SleepingSnoring or stopping breathing at nightFatigueObstructive Sleep Apnea AHIRHICPAP intolerant
Reason for referral
-COSMETIC DENTISTRY -ORTHODONTICS

-MIGRAINES, NECK & JAW PAIN -SLEEP APNEA & SNORING TREATMENT

-GUM (PERIODONTAL) THERAPY -DRUG FREE SEDATION (Nucalm)

SMART Dentistry (SAFE MERCURY AMALGAM REMOVAL TECHNIQUE)
Should be Empty:

SMART