Contact MyoFuture

Patient's Name

Parent/Guardian Name (if minor)

How would you like to be contacted?

I will try to accommodate you as much as possible

I am contacting you to discuss:

Mouth Breathing

Tongue Thrust

Oral Habit Elimination

Bruxism

Tongue/Lip Position

Lingual Frenum

tongue restriction

Sleep Disordered Breathing

Something Ele

Other Comments/Concerns

If there's anything else that you would like me to know prior to your call, please include it here.

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