Home
About
Treatments
Patient Resources
Doctor Forms
Telemedicine
Educational
FAQ
- Testimonials
Contact

Myofunctional Therapy Doctor Forms

Below are resources that dentists and other medical professionals can use to easily refer patients in online and printable format. Should you have any questions or need assistance please do not hesitate to contact Pat.

Printable Forms
Referral Source Form
Doctor introduction letter
Referral Source Myo Measurements
SPOTS screening tool

Fax: (402)513-7877

Patient Referral

Patients Name *

Date Of Birth

Age

Parent Name

Phone Number

Reason for Referral (please check all that apply)

Tongue Thrust R13.11
Thumb Sucking M26.59
Mouth Breathing R06.5
Ortho Relapse M26.11
Low tongue posture M26.59
Speech Disturbances R47.9
TMJD Muscle pain M26.69
Other breathing issues R06.89
Nail Biting M26.59
Malocclusion M26.29
Tongue-tie Q38.1
Open bite M26.22
Snoring R06.83
Obstructive sleep apnea G47.33

Other (Please describe)

Other Pertinent Information

Referring Doctor *

Phone

Fax

Address

File Upload