ENT REFERRAL

Thank you for your interest in an ENT referral for airway and sinus assessment. To help us provide the best care for your child, please complete the following information:

We appreciate you taking the time to fill out this form. The information you provide will assist in ensuring a thorough and accurate referral to the ENT specialist. Please answer the questions below to help us address your child's airway, sinus, and sleep-related concerns effectively.
Patient Information
Full Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Parent/Guardian Name

First NameLast Name
Relationship to the child
Parent/Guardian Contact Information
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Medical and Dental History
Does your child have any diagnosed medical conditions?

YesNo
If yes, please specify:
Is your child currently taking any supplements or medications?

YesNo
If yes, please specify:
Any allergies?
Has your child had any previous ENT or sleep assessments?

YesNo
If yes, please specify:
What symptoms does your child experience? (Check all that apply)

Mouth breathingSnoringDaytime fatigue/low energyTeeth grinding (bruxism)Speech difficultiesFeeding/swallowing challengesFrequent colds/sinus issuesHyperactivityLacks attentionHabits such as thumb sucking, dummy sucking or finger suckingPoor sleepSleep talkingSleep walkingOther
Other symptoms:
How long has your child been experiencing these symptoms?
Has your child been diagnosed with or suspected of having sleep-disordered breathing?

YesNo
Clinical Findings from Dental Examination

(Pre-filled by the dentist)
Examination Findings:

Tongue tie presentEnlarged tonsilsReduced jaw sizeOverbite/overjetOpen bite
Other:
Additional Information & Submission
Do you have any additional concerns or notes for the ENT specialist?
Please attach your dental report and any supporting documents here

Cancelof
Consent & Authorisation

By checking "Yes," you agree to allow us to share your child’s information with the ENT specialist for further assessment.
I consent to the sharing of my child’s information with the ENT specialist.

YES
Additional Information
We also offer services that can help address symptoms like mouth breathing, low energy, and other related issues through Myofunctional Therapy and Orthodontics, which may complement the ENT referral. If you would like more information about how our therapies can support your child’s health, please indicate below.

Yes, please contact me about Myofunctional Therapy and Orthodontic optionsNo, thank you
Thank you for completing the form. Once submitted, your referral request will be sent securely to our ENT specialist. Rest assured, all data submitted through this form is encrypted and handled with the utmost care to protect your privacy. You will receive confirmation once your referral is processed. If you have any questions or concerns, feel free to contact us directly.
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Thank you for your interest in an ENT referral for airway and sinus assessment. To help us provide the best care for your child, please complete the following information:

Patient Information

Parent/Guardian Contact Information

Medical and Dental History

Clinical Findings from Dental Examination

Additional Information & Submission

Consent & Authorisation

Additional Information