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Refer to Airways Myofunctional Therapy

Healthcare Professionals

We value and welcome professional referrals from all healthcare providers. When you refer to Airways Myofunctional Therapy, you can expect a high level of care for your patients, open communication and collaboration. If you have questions, please contact us.

Patient First & Last Name:

*

Age of Patient

*

Parent/Legal Guardian (if under 18)

Patient Phone Number

*

Patient Email

*

Referring Provider Name

*

Referring Provider Phone Number

*

Referring Provider Email

*

Please evaluate the following:

*

Please evaluate the following:

Tongue Thrust

Tethered Oral Tissues

Incorrect Resting Tongue Position

Symptoms of Sleep Disordered Breathing

Mouth Breathing

Oral Habit

Lip Incompetence

Orthodontic Relapse

TMJ/Facial Pain Concerns

Other

Additional Information:

Would you like a report emailed after our Initial Evaluation?

*

Would you like a report emailed after our Initial Evaluation?

A

Yes

B

No

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