Patient Referral
Patient Name
*
First Name
Last Name
Patient's DOB
-
Month
-
Day
Year
Date
Today's Date
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Month
-
Day
Year
Date
Telephone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Referring Office
Include contact information
Will your office send any diagnostic imaging (photos, radiographs, CBCT) ahead of the patient's consult? If so, please upload them below.
Yes
No
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Reason for Referral
Breathing/ Sleep Apnea
Mouth Breathing
Nasal Obstruction
Snoring/Sleep Apnea
Bruxism/Clenching
Insomnia
Chronic Fatigue
Uper Airway Resistance Syndrome
Oral Appliance Failure
CPAP Intolerance/Failure
Sleep Hygiene
Other
Anatomical Restrictions
Adenoid Hypertrophy
Enlarged Tonsils
Septal Deviation
Nasal Valve Collapse
Tongue-Tie (Lingual Frenulum)
Lip-Tie (Labial Frenulum)
Buccal-Tie (upper/lower)
TMJ/TMD Pain
Neck/Shoulder Tension
Craniofacial Pain
Other
Myofunctional Therapy
Restricted Tongue Mobility
Adequate LPS
Compensation Controlled
Ready To Schedule
Other
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Additional Information for Tongue Tie Patients
Has the patient already begun Myofunctional Therapy?
Yes
No
If yes, Therapist's Name:
Any limitations/ challenges in doing therapy?
Any other providers involved in this patient's care? (orthodontist, bodyworkers, etc?)
Submit
Should be Empty: