Patient Referral Form

Face First Myofunctional Therapy Referral Form

Please fill out our PIPA compliant client or self referral form. Clients can also self book on our Jane app https://facefirstmyo.janeapp.com

1 (250) 900-5590

Patient Information

First Name

Last Name

Birth Date

Gender

Male Female Other

Primary Phone Number

Email address

Parent/Guardians Name If Applicable

Reason for Referral

Chief Concerns/Orofacial Myofunctional Disorder's (OMD) Choose all that apply

Airway / Breathing Issues

Mouth breathing, snoring, open-mouth posture, sleep issues

Tethered Oral Tissues

Suspected or confirmed tongue-tie or lip-tie)

Tongue Rest Position / Thrust

Low tongue posture, forward or lateral tongue thrust, speech lisp

Chewing & Swallowing Concerns

Messy or loud eating, pocketing food, texture aversions, atypical swallowing

Oral Habits

Thumb, finger, pacifier, or tongue sucking

Jaws & Facial Muscles

MJ pain/clicking, teeth clenching/grinding, facial muscle strain/chin dimpling)

Dental / Orthodontic

Narrow arches, open bite, crossbite, dental wear or orthodontic relapse

Please List Any Additional Information or Concerns

Referring Practitioner's Name

Referring Business/Office Name

Referring Practitioners Telephone Number

Referring Practitioners Email

Please add any relevant photos, x-rays, panoramic, cephalometric, CBCT, or documents below. Please note we only use secure PIPA compliant file uploading platform

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