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Professional Referral Form
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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
Please check reason for referral below.
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Please include the following information for the patient you are referring: Name, date of birth, address, phone number, email address (if applicable)
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