Name *

First Name

Last Name

Have you experienced any symptoms?

Please check all that apply

Mouth Breathing

Open Bite

Tongue Thrust

Tongue/Lip Tie

Oral Habits (soother, bottle, thumb sucking etc.)

Speech Concerns (delay, understanding, lisp etc.)

Snoring/Sleep Apnea

TMJ/TMD (Jaw Pain)

Orthodontic Relapse (Teeth Shifting After Braces)