Refer a patient to KenmoreMyo

KenmoreMyo

Dave Henrichsen, RDH, Myofunctional Therapist

425-998-8625

Date of Referral

Patient's Name

Patient Date of Birth

Parent/Guardian Name (if minor)

Patient preferred phone number

Email address

Referring Doctor

Please evaluate and treat the following:

Tongue Thrust

Facial Rest Posture

Thumb/finger habit

Tongue/Lip Posture

Abnormal Swallow

Lingual Frenum Restriction

Mouthbreathing

Snoring/Sleep Apnea

Other Comments/concerns

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