OMT of York
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Refer a Patient
Patient Name
Guardian Name
If patient is under 18
Patient Birthdate
Date
Gender
Male
Female
Patient (or Guardian) Phone
Referring Provider and Office
*
Referring Provider's Email
*
Please Evaluate for the Following
Tongue Thrust
Short Upper Lip
Sucking Habit
Low Tongue Posture
Tongue Tie
Nail Biting
Lip Competence
Drooling
Other Oral Habit
Other
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