Pediatric Airway Patient Interest Form

Pediatric Airway Interest Form

Thank you for your interest in Pediatric Airway treatment with Dr. Shannon. Please fill out this form and we will be in touch about scheduling an appointment. We are a family practice and love seeing the whole family! While we do not specialize in operative pediatric dentistry, we offer airway-focused exams to help build the right care team for children 3 and under. We typically do not begin seeing children for cleanings until age 4. Please note: Airway exams and cavity/cleaning visits are separate in our office. Thank you for your support of our vision helping patients breathe, sleep, eat and thrive!
Patient Name

First NameLast Name
Patient date of birth

MonthDayYear
Date
Age of child
Parent Name

First NameLast Name
Parent email
example@example.com
Parent phone number
Please enter a valid phone number.
How would you like to be contacted?

emailphone callany of the above
What is your main reason for contacting Dr. Shannon?

Tongue tieSleeping/breathing/symptoms concernsLack of space for teethInterested in proactive treatment to optimize growthCurrent patient in treatment with Dr. Shannon transferring careI am interested in a cleaning/cavity check visit as well
What type of appointment are you interested in scheduling?

Age 3 and under airway screening examAge 4+ comprehensive airway evaluation and recordsDental cleaning/cavity check/new patient exam"Discovery visit"- to get to know more about the office to see if we are a good fit
How did you hear about Dr. Shannon and the Myogrow Airway Center?
Thank you for your interest, we will be contacting you soon!

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