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Sign-Up Form:

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

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Person filling out this form if not the patient

First NameLast Name
Relationship to the patient
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 GrindingTongue TieCrowded TeethMisaligned jawsOther
Have you had a recent dental visit within the past 6 months?

YesNo
How long ago was your last visit?
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 personalised 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
Preferred dates of consultation:
By submitting this form, you’re expressing your interest in Myofunctional Orthodontics and Craniosacral 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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Patient Information

Health Status