Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Preferred contact method
Best time to reach out
Have you had a history of breathing issues, ie allergies, asthma, mouth breathing?
*
Yes
No
Do you get frequent headaches?
*
Daily
Weekly
Morning
Night time
After eating
Do you have neck or shoulder pain?
*
Yes
No
Do you have difficulty chewing and / or swallowing?
*
Yes
No
Do you have missing teeth?
*
Yes
No
Do you feel you bite heavier on your front teeth than your back teeth?
*
Yes
No
Do you or have been told, you clench or grind your teeth?
*
Yes
No
Do you have unresolved Jaw or ear pain?
*
Yes
No
Does your jaw click or pop? Has your jaw ever clicked or pop?
*
Yes
No
Does your jaw make a grating noise when you chew?
*
Yes
No
Other symptoms you are experiencing?
Submit
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