Provider making the referral

Clinic

Doctor's name

Patient's info

First Name

ReferralName

Last Name

ReferralLastName

Email *

ReferralEmail

Date of birth

Referral’s Phone *

Patient/Guardian name and email

Referral Notes

ReferralNotes

Reasons for Referral

Adults

TMJ Disorders (jaw pain, clicking, popping, limited movement)

Sleep Apnea & Snoring (diagnosis and treatment including oral appliances)

Chronic Headaches or Migraines (related to jaw tension)

Bruxism (Teeth Grinding/Clenching)

Facial Pain or Muscle Tension

Orthodontic or Jaw Alignment Concerns (pre/post orthodontic evaluation)

Infants & Children

Tongue and Lip Tie (ankyloglossia, restrictive tongue/lip)

Difficulty Breastfeeding (poor latch, nipple pain, low milk supply)

Jaw Development Issues (narrow palate, underdeveloped jaw)

Speech Delays related to tongue mobility

Sleep Issues in Children (snoring, restless sleep, mouth breathing)

Other

Referral for Collaborative Care (pediatricians, lactation consultants, dentists, ENT specialists)

Professional Advice on Airway, Sleep, and Jaw Health

Restorative

All Pre-orthodontic restorative treatment is complete?

General Health & Wellness

Postural or Airway Issues (mouth breathing, tongue posture)

Difficulty Sleeping or Poor Sleep Quality

Post-Surgical Follow-up (e.g., post-frenectomy evaluation)

Preventive Care (early intervention in infants for tongue/lip tie or jaw development to prevent future issues)