Provider Referral Form Referring Doctor * Patient Name * First Name Last Name Patient's Phone Number * (###) ### #### Patient’s DOB * MM DD YYYY Patient’s Parent/Guardian Name (if minor) First Name Last Name Reason for Referral: * Myofunctional therapy evaluation Tethered oral tissues Pre-orthodontic therapy Oral appliance collaboration Tongue thrust Low tongue posture Open mouth posture Mouth breathing Thumb/Finger/Sucking habit Other, please specify below Other: Special Note to Myofunctional expert: Thank you for your referral! Awareness is KEY! Take Our Free Self Assessment!
