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Questions? Call, text or email Elizabeth Pierce, RDH, OMT:

Date of Referral

Patient First Name

Patient Last Name

Patient Email Address

Patient Phone Number

Referring Practitioner Name

Referring Practitioner Email Address

Referring Practitioner Phone Number

Please Evaluate the Following

Abnormal Swallow

Facial Rest Posture

Lingual Frenum Restriction

Mouth Breathing

Snoring / Sleep Apnea

Thumb / Finger Habit

Tongue / Lip Posture

Tongue Thrust

Comments / Concerns

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