Hello again...

I can't wait to meet you! I know you may have tried everything under the sun and I am so excited that Myofunctional Therapy might be the BIG turning point you've been waiting for. Please fill out the information below to contact me with questions you have prior to our scheduled Comprehensive Initial Exam.

First Name

Last Name

Email

Referred By

Check all that apply to you * Required

Pacifier Use

Bottle Feeder

Thumb Sucker

Mouth Breather

Snorer

Sleep Apnea

TMJ Pain/ Headaches

Open Bite/ Tongue Thrust

Bedwetting

Behavioral Issues

Interrupted Sleep

Always Tired

Goal with Therapy

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