Provider Referral
Referral for TMJ-focused manual therapy evaluation & treatment using intraoral massage with Erica Fenech, LMT.
Patient Information
Patient Name
*
First Name
Last Name
Patient Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email
*
example@example.com
Referring Provider Information
Referring Provider Name
*
First Name
Last Name
Practice Name
*
Referring Provider Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Signature
*
Reason for Referral
*
TMJ pain/tension
Bruxism/clenching
Headaches
Facial pain
Limited jaw opening
Cervical tension
Muscle tenderness
Orthodontic-related tension
Stress-related jaw tension
Other
Additional notes about patient
Submit Referral
Submit Referral
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