Whitefish Myofunctional Therapy

Client Information

First name

Last name

Date of birth

Occupation

Gender

Date

Phone number

Email address

Address

Referral From:

Self

Doctor/Practitioner asked me to call

Referred by:

What are your primary concerns?

Tongue Thrust

Mouth Breathing

Swallowing Issues

Snoring/Sleep Apnea

Lingual/Lip Frenum Restriction (tongue tie)

Thumb/Finger/Sucking Habit

Tongue/Lip Resting Posture

Any other Concerns or Comments?

Thank you for taking the time to reach out. I will be in touch with you soon!

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