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Patient's Name
Guardian's Name (If patient is under 18)
Patient's Birth Date
Phone (Patient or Guardian)
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Referring Providers Email
Referring Provider and Office
Please Evaluate for the Following
Tongue Thrust
Low Tongue Posture
Lip Competence
Short Upper Lip
Tongue Tie
Drooling
Sucking Habit
Nail Biting
Speech Issues
Swallowing Difficulty
Picky Eating
Feeding Issues
Other Oral Habit
Refer a Patient
Services
Speech Language
Myofuntional Therapy
Feeding and Eating
Swallowing
Breastfeeding
Parkinson's
Resources
Patient Library
About
Meet the Team
FAQ
Contact
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