Myofunctional Support Request
Use this form to apply for our reduced rate services. Applicants will be taken on a first come, first serve basis, with space and available time slots limited. We will send you a PayPal invoice and once paid will call to schedule you as per mutual availability for a tele-therapy session via Doxy.Me. Please give accurate answers in order to receive a response. Please fill out this form in it's entirety prior to submission.
Email *
Contact Full Name *
Patient/Child's Full Name *
Patient/Child's Birthdate *
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Contact Telephone Number *
Was a tongue tie diagnosed by a doctor? *
Was a surgical release scheduled already? *
Can you afford the $35 per session rate? Assume a range of 3-5 sessions prior to release, if necessary, and 2 sessions after. *
What days are you available for your initial consultation and assessment? (Check all that apply) *
Required
For the pay-what-you-can rate, what rate per session would you be able to afford and why?
We request all patients fill out and sign our client agreement and informed consent forms. Do you consent to receiving these forms in your e-mail upon completion of this form? *
Required
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