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Referral Form
Harmony Myofunctional Therapy
780-238-2335
reception@harmonymyotherapy.com
harmonymyotherapy.com
Patient Name:
Patient Age/D.O.B.:
*
Patient Email:
*
Patient Contact Number:
Patient Address:
*
Parent:
*
Chief Concerns:
Restrictive Sublingual Frenulum
Restrictive Maxillary Labial Frenulum
Restrictive Mandibular Frenulum
Restrictive Buccal Frenulum
Tongue-Thrust
Anterior Open Bite
Posterior Open Bite
Mouth Breathing
Dysfunctional Breathing
Thumbsucking/Finger Sucking
Other Negative Oral Habit
Concerns for Craniofacial Growth and Development
Orofacial Pain
Improper Tongue Rest Posture
Sleep/Airway
Speech
Comments:
*
Referring Provider and Provider Contact:
*
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SERVICES
QUESTIONS AND INFO
ABOUT
REFERRAL
HARMONY INTEGRATIVE
OROFACIAL HEALTH
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CONTACT
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