Patient Referrals Referral Provider * Provider's Email * Patient's Name * First Name Last Name Patient's Email * Patient's Phone * (###) ### #### Patient's DOB MM DD YYYY Symptoms Noted * Tongue tie Tongue thrust Open bite or cross bite Mouth breathing Dental crowding / ortho relapse Grinding, clenching, TMJ issues Snoring, sleep apnea Headaches and/or migraines Digestive issues Allergies and/or food sensitivities Speech/articulation issues Other (please note in message box below) Message * Note any additional concerns and the reason you are recommending myofunctional therapy for your patient. Thank you for your referral to MyoHarmony Myofunctional Therapy! Printable PDF Referral Print Library Referral Card Patient Brochure Patient Rack Card Screening Guide for Dental Providers Screening Guide for BodyWorkers