Dr Referral

E-File

First Name

Last Name

Date of Birth

Phone #

Email Address

First Name

Last Name

Phone #

Email Address

Reason For Referral

DIAGNOSIS:

Anklyoglossia

Dentofacial Functional Abnormality

Oral Dysphagia

Feeding Difficulties

Speech Disturbances

Sleep related Bruxism, Grinding

Mouth Breathing

Tongue Thrust, Thumb/ Finger Habit

Bitting: cheek or lip

TMJ Dysfunction

Facial Muscle Spasms

Abnomalies of dental arch, Anterior Open Bite

Abnomalies of dental arch, Posterior Open Bite

For Evaluation and Management of Speech, Swallow, & Oral Motor Treatment Including:

Exam Evaluation

Treatment Exercise

Oral Habit Intervention

Myofacial Release Treatment

Treatment, Functional Performance

Dysphagia Treatment

Speech Treatment

Headache or facial pain

Oral Incompetence due to Short Upper & Lower Labial Frenulum

Abnomalies of dental arch, Excessive Horizontal overjet

Abnomalies of dental arch, Crossbite

Abnomalies of dental arch, Inadequate interarch distance