Name *

First Name

Last Name

Phone *

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Signs & Symptoms *

Check all that apply:

Tongue/Lip Tie

Mouth Breathing

Tongue Thrust

Headaches/Migraines

Teeth Grinding/Clenching

Orthodontic concerns/relapse

Chewing/Swallowing concerns

Snoring/Sleep Apnea

I want to prevent Sleep Apnea

I want to prevent Orthodontic problems