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Sign-Up Form:

Thank you for your interest in Myofunctional Therapy. To ensure we provide the best care, please answer the following questions:
Patient Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Ethnicity
Phone Number
Please enter a valid phone number.
Email
example@example.com
Health Status
Have you been diagnosed with any of the following conditions? (Check all that apply):

SnoringSleep ApneaTMJ (Jaw Pain)Mouth BreathingTeeth GrindingOther
Do you currently use any of the following treatments? (Check all that apply):

CPAP MachineOral ApplianceOther
Have you had a recent sleep study?

YesNo
Do you have a referral from a healthcare professional?

Yes, I have a referral.No, I do not have a referral.
If you answered "No" to either question 7 or 8, we’ll contact you to schedule a consultation before proceeding with the screening form.
Confirm Email
Please briefly describe your primary concern or reason for seeking therapy:
Are you ready to commit to a personalized treatment program and follow-up therapy sessions?

Yes, I’m committed to improving my health.I’m still considering my options.
Preferred Consultation Time:

MorningAfternoonEvening
By submitting this form, you’re expressing your interest in Myofunctional Therapy. We will review your responses and contact you accordingly. If needed, we’ll help guide you toward the necessary next steps for treatment.
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