MYOFUNCTIONAL THERAPY INTAKE FORM

Thank you for your interest in getting an evaluation and/or treatment for your child’s oral functional skills. Your orthodontist/dentist has recommended we take a look at your child so we can help them with their dentistry needs. The first session takes 30-60 minutes. We will then discuss our findings with the doctor to help get your child what they need. It is possible your health insurance will cover these appointments. You can contact them to find out. If you hope to bill your health insurance please note the information below. Once our office receives this information we will contact you to schedule the first appointment when you are ready for your child to be scheduled. For additional information feel free to call our office at 770-209-9826 or email at info@pediaspeech.com .

Myofunctional Therapy Intake Form

This field is for validation purposes and should be left unchanged.

Child's Name:(Required)

DOB:(Required)

Age:(Required)

Parent's Name:(Required)

Email:(Required)

Phone Number:(Required)

Provider's (orthodontist/dentist) Name:(Required)

Are you ready to schedule the first appointment?(Required)

Yes

If no what date would you like to begin?

Reason for referral:

Scheduled for expansion

Tongue tie

Articulation issues

Tongue thrust

Health Insurance Plan Name:

Group #:

Member #:

Have Questions?

Contact PediaSpeech

MYOFUNCTIONAL THERAPY INTAKE FORM

Myofunctional Therapy Intake Form

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