Sophia Tsang BSc, RDH, COM™
 sophia@apexmyofunctionaltherapy.com
  Currently available Tuesday, Wednesday and Thursday
  Skype appointments available as well

Name of The Referring Individual

Profession of The Referring Individual

Contact Information of The Referring Individual

Patient's Information - Individual Being Referred:

Name

Contact Information

Reason for Referral
Noxious Habits (Thumb sucking; Lip-biting, nail biting, and Deviate swallowing)Trichotillomania (Hair Pulling)Bruxism (Teeth Grinding and Clenching.)Pre-op and Post-op with frenotomy orofacial surgery/Tongue-tieTongue ThrustSpeech AssessmentDroolingMouth BreathingJaw Pain, Facial Tension, and Temporomandibular Disorders (TMD)Mild Sleep Apnea and SnoringOpen Bites and Cross bites.Pre, during, and post orthodontics

Treatment Goals and Additional Information