Referral Form
HIPAA Compliant
Referral Intake Information
Full Name of Referred Individual
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Name/ Practice Name
*
Referring Provider Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Provider Email
*
example@example.com
Professional Specialty/Referral Source
Please Select
Dentist/Pediatric Dentist
Oral Surgeon
Orthodontist
Periodontist
ENT
Pediatrician
Sleep Specialist
Speech Language Pathologist
Select Applicable
Tongue Thrust
Open Bite
High Narrow Palate
Thumb/Finger Sucking
Grinding (Bruxism)
Tongue Tie Assessment
Select Applicable
Pre/Post Frenectomy Re-education
Post-Jaw Surgery Rehabilitation
TMJ Dysfunction
Select Applicable
Relapse after braces
Mouth Breathing
Open Bite
Pre-Expansion Treatment
Difficulties with Palatal Expansion
Abnormal Swallowing Pattern.
Select Applicable
Gingival Recession (related to muscle pull or low tongue posture)
Persistent Inflammation (often linked to mouth breathing/dry mouth)
Post-Frenectomy Rehabilitation
Tongue Tie affecting periodontal health
Preparation for Gingival Grafting (to ensure muscle tension doesn't compromise the graft)
Select Applicable
Chronic Mouth Breathing
Deviated Septum (Post-Surgical follow-up)
Enlarged Tonsils/Adenoids
Allergic Rhinitis support
Select Applicable
ADD/ADHA
Attention Difficulty
Bedwetting
Failure to thrive (feeding issues)
Picky Eating (Texture issues)
Restless Sleep/Difficulty Waking
Snoring
Speech delays
Select Applicable
Obstructive Sleep Apnea (OSA) adjunct therapy
Upper Airway Resistance Syndrome (UARS)
Snoring
Restless Sleep
Select Applicable
Persistent /r/ or /s/ distortions
Interdental Lisp
Oral Phase Swallowing issues
Weak Tongue Lateralization
What stage of treatment is the referred patient in?
Our office is monitoring to see if OMT will help conditions (ex: prior to tonsillectomy, day and night nasal breathing prior to evaluation for attention difficulties)
OMT requested as part of patient treatment in referring office (ex: proper tongue rest position prior to expansion).
We are referring because we have completed our treatment and want OMT as an adjunct for habituation.
Diagnosis or Additional Comments
Referring Office Documents
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