We appreciate the thoughtful referral of your patients. Please let us know a little bit about the symptoms below by clicking the “Make Referral” button.

If you would ever like to learn more about Myofunctional Therapy programs, please send me an email about my Lunch & Learns and Zoom Break Chats (Myo & Muffins) or check out some research articles under the “Professionals” tab.

Intake Form

Name *

First Name

Last Name

Email *

Assessment Findings/Concerns

Check all that apply

Mouth Breathing

Open Bite

Tongue Thrust

Tongue Tie

Frenum Pulls

Restricted Maxilla

High/Narrow Palate

Oral Habits (soother, bottle, thumb sucking)

Snoring/Sleep Apnea

TMD pain

Bruxism

Scalloped Tongue

Large Tonsils/High Mallampati Score

Orthodontic Relapse

Speech Concerns

Additional Symptoms or Notes

Anything else you wish to add?

Other Referrals Made

Have other professional referrals (ortho, speech therapy, sleep clinic, physio, chiro etc.) been made?

Thank you for the kind referral!

Kari Panting Slade Dental Hygiene Professional Corporation

Something To Smile About - Dental Hygiene Services and Myofunctional Therapy

Kari Slade RDH

446 Grey St. Unit 101, Brantford. something2smileabout.rdh@outlook.com

Schedule an Appointment