MyoThrive Consultation Request
Thank you for your interest in MyoThrive. Complete this short form to request a consultation and learn whether myofunctional therapy may be a good fit. Submitting this form does not confirm an appointment. Lindsey will contact you to discuss next steps.
Who is the consultation for?
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Myself
My child
Someone else
Your full name
*
First Name
Last Name
Client/patient full name
*
First Name
Last Name
Client/patient age
*
Email address
*
example@example.com
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred way to be contacted
*
Text
Phone call
Email
What would you like help with? (Select all that apply)
Mouth breathing
Snoring or sleep concerns
Tongue posture
Tongue thrust or swallowing concerns
Speech concerns
Oral habits (thumb/finger/pacifier)
Jaw pain or TMJ concerns
Orthodontic support
Feeding or chewing concerns
Other
Briefly tell me what you have noticed or what brings you to MyoThrive. (Please do not include urgent or highly sensitive medical information.)
Has a provider referred you?
No
Dentist
Orthodontist
Pediatrician/physician
Speech-language pathologist
ENT
Other
If referred, provider name
Best days/times to reach you
How did you hear about MyoThrive?
Instagram
Facebook
Friend or family
Dental/medical provider
Google/web search
Other
Request My Consultation
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