Referral Forms for Adults for Tongue Ties & Myofunctional Therapy

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This form is intended for for adults over the age of 18 years being referred for lip/tongue ties or for myofunctional therapy. This form can be filled out by a medical professional or as a self referral.

Referral From *

Phone Number or Email *

Reason for Referral (please describe below) *

Tongue Tie

Myofunctional Therapy

Other:

Required

Reason for Referral/Concerns *

Patient First and Last Name *

Best Number to Contact *

Email *

Address *

Have you have seen any other health care professionals for tongue tie related issues?

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