PATIENT REFERRAL FORM Please fill out the form below Patient's Name Patient's Age If patient is a minor, parent's name: Patient's Contact Information: Reason for Referral: Tongue Tie ReleaseTongue/Lip Tie ConsultationGrowth GuidanceForward OrthodonticsMigrainesTMJEstheticsMouth BreathingSuspected BreathingDisordered SleepBed-WettingRecurrent Ear InfectionSnoringADHDOther If you answered "other" please list the reason here: Current Therapies (i.e. speech, myofunctional therapy, orthodontics) Referring Provider Please prove you are human by selecting the Cup. Get a head start before coming in, contact us to receive our patient forms and resources. Request Patient Forms
