Provider Referral Form
Please fill this form out if you have a patient you would like for us to reach out to, to start virtual Myofunctional Therapy.
Date
-
Month
-
Day
Year
Date
Referring Healthcare Provider Name:
First Name
Last Name
Introducing (patient name) for evaluation for orofacial myofunctional disorders, swallowing habits, sucking habits, or other.
First Name
Last Name
Please Select
Please Select
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Age
Parent(s), if minor
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Primary Reason for Referral:
Select all that apply:
Ortho Relapse (M26.11)
Tongue Thrust (R13.11)
Atypical Swallow (R13.11)
Oral Habits/ Digit Sucking (M26.59)
Low Tongue Rest Posture (M26.59)
Dentofacial Functional Abnormalities (M26.50)
Tongue Tie/ Ankyloglossia/ TOTS (Q38.1)
Orofacial Muscle Pain (M26.29)
Speech Disturbances (R47.9)
Mouth Breathing (R06.5)
Other Breathing Issues/ Snoring (R06.89)
Other, please describe
If other, please describe:
Has the patient had an airway screening?
Please Select
Yes
No
Has the patient had a Cranial 3D Screening?
Please Select
Yes
No
Has the patient had a sleep study?
Please Select
Yes
No
Doctor/Provider, what objectives do you hope to accomplish with myofunctional therapy?
What is your timeline for treatment?
I am waiting for you to finish therapy.
I am willing to phase treatment in order to accommodate therapy.
I am placing an orthodontic appliance and need to coordinate therapy.
Not applicable.
Signature of Provider
Email address for Provider
example@example.com
Good contact number for Provider
Please enter a valid phone number.
Next Step:
Call me to discuss finding and treatment recommendations.
Email me to discuss finding and treatment recommendations.
None.
Please email any correspondance to myosupport@toothpillow.com
Thank you!
Submit
Submit
Should be Empty: