Fairview Dental

Myofunctional Therapy Referral Form

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Comments

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Name(Required)

Email(Required)

Phone(Required)

Habit Elimination(Required)

Habit Elimination (thumb/finger sucking, nail biting, lip licking)

Tongue Thrust

Mouth Breathing (Lip Incompetence)

Pre and Post Frenectomy

Incorrect Chewing and Swallowing Pattern

Consult for Myofunctional Therapy

Message(Required)

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