Patient Name *

First Name

Last Name

Reason for referral:

Check all that apply*

Tongue Tie

Lip Tie

Tongue Thrust

Mouth Breathing

Oral Habit(s)

Low Tongue Posture

Lip Incompetence or Short Upper Lip

Orthodontic Retention/Relapse

Malocclusion

Lip Trapping

Symptoms of Sleep Disordered Breathing

Clenching or Grinding

TMJ Symptoms

Low Muscle Tone

Speech Concerns

Other