Patient Referral Form

Providers please fill out referral form for new patients.

First Name

Patient Phone Number

Last Name

Date of Birth

Reason for referral: (check all that apply)

Orofacial Myofunctional Exam/Therapy

Speech and Language Evaluation

Abnormal Swallow and/or Tongue Thrust

Mouth Breathing

High and/or Narrow Palatal Arch

Restricted Lingual Frenum

Presenting Symptoms:

Class I

Class II

Class III

Open Bite

Cross Bite

Overbite

Overjet

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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