Oral Motor Provider Questionnaire
We would really appreciate if you can provide the following answers.
Provider/Practice Name
Best Contact Person
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Best Email
example@example.com
Location(s) - List City and State
Oral Motor Dysfunction Evaluations and Therapy
Infants up to 2 years old
2 years old up to 5 years old
5 years old up through 17 years old
Adults
In House Orofacial MyoFunctional Therapy
Refer Out Orofacial MyoFunctional Therapy
Other
CBCT Airway Scans offered
Infants up to 2 years old
2 years old up to 5 years old
5 years old up through 17 years old
Adults
Other sleep Apnea Services
Other
Oral Tie Releases
Infants up to 2 years old
2 years old up to 5 years old
5 years old up through 17 years old
Type option 7
Laser
With Sutures if needed
Anesthesia offered
Other
Orthodontic Expansion (List types of appliances in Other)
Infants up to 2 years old
2 years old up to 5 years old
5 years old up through 17 years old
Adults
Other
Lactation Counseling
We already offer in house
We refer out
We would like TBWG to offer a community Lactation Support Group at our location.
Other Functional or Holistic Services offered
Fluoride Free options
Hydroxyapatite Offered
Low radiation X-rays
Other
We would like to work with The BreatheWell Group as a preferred provider.
I would like more information about the services
Please add us to your referral email list.
We are interested in scheduling a virtual team meeting to learn more about how we can collaborate.
Not interested at this time.
Other
Other Treatment or Applicances
TMJD
Sleep Apnea
Other
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