Patient Referral

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541.81.SMILE (76453)

Use tab to navigate through the menu items.

Patient Name

Parent/Guardian Name

Date of Birth

Phone

Email

Referred By

If no answer, is it ok to leave a message at the number listed? *

Yes

No

Please evaluate the following:

Tongue thrust swallowing p

Tongue-tie/restricted lingual frenum

Open mouth rest posture

Post-frenectomy care

Mouth breathing

Thumb/finger sucking habit

Other concerns noted:

TMJ Disorder/pain/discomfort

Speech problems

Adenoid/tonsil hypertrophy

Headaches/clenching/grindinge

Sleep apnea/sleep disordered breathing/snoring

Other concerns not listed above?

Thank you for referring a patient! I'll reach out to them as soon as I can.

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