Whitefish Myofunctional Therapy - Doctor/Provider Referral Form

Encrypted Secure Referral Form

Please correct the errors described below.

Client Information

First name

Last name

Date of birth

Occupation

Gender

Date

Contact Information

Phone number

Email address

Address

Referral From:

Doctor/Practitioner

Referred by:

What are your primary concerns?

Tongue Thrust

Mouth Breathing

Clenching/Grinding

Snoring/Sleep Apnea

Lingual/Lip Frenum Restriction (tongue tie)

Thumb/Finger/Sucking Habit

Low Tongue Posture

Relapse of Orthodontic Treatment

Sleep Disordered Breathing Concerns

TMJ/TMD Symptoms

Any other Concerns or Comments?

I will stay in touch with our findings and progress. Thank you for your referral ! Lori

Your information will be encrypted.

Lori Miller, COM®

Owner, Certified Orofacial Myologist, Whitefish Myofunctional Therapy

whitefishmyo@gmail.com

Telephone 360-317-7444
www.whitefishmyo.com

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