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Referral Form
Referring Professional
Phone
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Client First Name
Date Of Birth
Client Last Name
Phone
Reason for Referral
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Tethered Oral Tissues
Oral Breathing and/or Low Tongue Posture
Tongue Thrust/Abnormal Swallow Pattern
Dentofacial underdevelopment
Sleep Disturbances
Clenching/Grinding
Noxious Habits- Prolonged pacifier/bottle use, nail biting, cheek/tongue chewing, etc.
Orthodontic Relapse and/or Tongue Thrust
Additional relevant information...
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Thank You!
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