Patient Referral Form

Please consider this patient for an orofacial myofunctional therapy (OMT) evaluation. OMT assesses oral muscle patterns and functions that may affect rest posture, swallowing, breathing habits and orthodontic care.

Don't fill this out if you're human:

Patient Information

Date of Birth

Reason for Referral (check all that apply)

Tongue • Lips • Swallow Tongue thrust / atypical swallow Low or forward tongue rest posture Poor lip seal / facial compensation Reduced tongue, lip or cheek control Limited tongue mobility / restriction Pre-/post-frenectomy support

Breathing • Airway • Sleep Habitual mouth breathing Nasal-breathing rest posture concerns Snoring / sleep-related concerns*

Dental • Orthodontic Open bite / functional bite concerns Evaluation before / during braces Post-orthodontic functional retraining Oral habit affecting teeth or bite

*Sleep-related concerns require appropriate medical/sleep evaluation before OMT treatment.

Additional Comments

Referring Provider

Date

OMT is collaborative care. Medical, airway, sleep, dental and orthodontic conditions are managed by the appropriate provider.

In-office orofacial myofunctional therapy in Janesville, Wisconsin. Sessions by appointment.

Quick Links

Home
What Is OMT?
About
Pricing
Contact

Contact

Nikki Arn RDH, OMT

4407 Milton Ave
Suite #124
Janesville, WI 53546

(608) 315-1222

In-office sessions in Janesville, WI
Virtual sessions nationwide
By appointment only

View Training Certificate