Referral Form

* This form is intended for health providers to fill out on your behalf

Name of Referring Doctor

Patient's First Name

Patient's Last Name

Patient's Date of Birth * required

Code

Patient's Preferred Phone Number

Patient's Email

Reason For Referral — Please Select ALL That Apply * Required

Open Mouth Rest Posture

Narrow / High Palate

Noxious Oral Habits

Tongue Thrust

Tethered Oral Tissues

Articulation Concerns

TMJ Pain

Malocclusion Concerns

Sleep Concerns

Other:

Current or Recommeded Orthodontic Treatment * Required

YES

Comments:

*If the patient is under 18 years of age, please include a contact name of a parent/guardian in the field below. Thank you!

Thank you for your referral!

Entrusting us with your patient's care is of the highest regard and we are thrilled to help them work towards their goals of overall health and wellness!

Contact Us

First Name

Last Name

Write a message

Thanks for submitting!

Open by appointment only

Please email for inquiries*

807 355 3102

myofunctionaltherapytbay@gmail.com

308 Red River Rd

Thunder Bay, ON P7B 1B1

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Please Note: The information on this website is for informational purposes only. A thorough comprehensive assessment is required to properly evaluate orofacial function and range of motion.

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