Referral Form to GlossaMyo

Date of Referral

Patient's Last Name

Patient's First Name

Patient Date of Birth

Parent/Guardian Name (if Minor)

Phone Number

Email address

Referring Doctor

Please Evaluate and Treat the following:

Abnormal Swallow

Mouthbreathing

Snoring/Sleep Apnea

Thumb/finger habit

Tongue/Lip Posture

Tongue Thrust

Lingual Frenum Restriction

Facial Rest Posture

Others

Other Comments/Concerns

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