Name of Referring Clinician *

First Name

Last Name

Parent Name (include if guardian of patient)

First Name

Last Name

Patient Name

First Name

Last Name

Phone *

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Reason for Referral *

Noxious Habits (incl. Thumb sucking; Lip-biting, nail biting, and Deviate swallowing)

Trichotillomania (Hair Pulling)

Bruxism (Teeth Grinding and Clenching)

Mild Sleep Apnea & Snoring

Pre-op and Post-op with frenotomy orofacial surgery

Tongue-tie

Tongue Thrust

Speech Assessment

Nail Biting

Orthodontics

Body Posture

Drooling

Mouth Breathing

Jaw Pain, Facial Tension, and Temporomandibular Disorders (TMD)

Mild Sleep Apnea and Snoring

Open Bites and Cross bites.

Pre, during, and post orthodontics

Breathing Wellness Programs

Airway Integrated Dentistry / Sleep Disordered Breathing

Developmental Epigenetic Orthodontics

Myobrace Integrated Programs

Healthy Start Integrated Programs

Temporomandibular Disorders

Breathing Wellness Programs

Other (use comment field below)