Reason for referral (Please fill out required information for preferred consultation):

Sleep Consultation

Please check off symptoms that apply to the patient (if known):

Invisalign / Expansion Consultation

Please check off symptoms that apply to the patient (if known):

If yes, please fill out sleep consultation above.

If yes, please fill out orofacial myofunctional therapy consultation

Frenectomy Consultation

Please check off frenulum to be assessed and additional information (if known):

If yes, please fill out Orofacial Myofunctional Therapy consultation below.

Orofacial Myofunctional Therapy Consultation:

Please check off symptoms that apply to the patient (if known):

If yes, please fill out sleep consultation.

Please indicate if any radiographs were taken within the last year: