Please complete the referral form through the link below Contact Us Refer a Patient Patient Name * First Name Last Name Parent/Guardian Name First Name Last Name Patient (or Guardian) Phone * (###) ### #### Referring Provider and Office * First Name Last Name Referring Provider's Email * Please evaluate for the following: Tongue Thrust Mouth Breathing/low tongue posture Tongue Tie Lip Competence Drooling Sucking Habit Other Oral Habit Abnormal Swallow Facial Rest Posture Ortho Relapse Additional Information Thank you for trusting your patient to our care. We look forward to providing the best for their overall health and wellness. We will be in touch following their evaluation to keep you informed of any therapy recommendations.-Heartland Myo-
