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Referral for Oral Dysfunction Form – DentalCareXtra
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Referral for Oral Dysfunction Form – DentalCareXtra
Referral for Oral Dysfunction Form - DentalCareXtra
Ensuring the best possible outcomes for our patients
Referring Clinic
(Required)
Practitioner Name
(Required)
First
Last
Referring Practitioner Email
(Required)
If you are not the above Practitioner please complete your name below.
Other Practitioner First Name
Other Practitioner Surname Name
Patient Details
First Name
(Required)
Last Name
(Required)
Date Of Birth
(Required)
DD slash MM slash YYYY
Guardian's Name
(Required)
First
Last
Mobile
(Required)
Confirm Email
(Required)
Email
(Required)
Degree of Urgency
(Required)
High
Medium
Low
Symptoms
Incorrect Swallow Pattern
Yes
No
Learning Difficulties
Yes
No
Colic Symptoms
Yes
No
Incorrect Chewing Patterns
Yes
No
Narrow Upper Arch
Yes
No
Communication Difficulties
Yes
No
Poor Lip Competence
Yes
No
Cross Bite
Yes
No
Feeding Swallowing Difficulties
Yes
No
Bedwetting
Yes
No
Crowded Teeth
Yes
No
Mouth Breathing
Yes
No
Low Tone
Yes
No
Snoring
Yes
No
TMJ Dysfunction
Yes
No
Poor Head Control
Yes
No
Poor Posture
Yes
No
TMJ Dysfunction
Yes
No
Incorrect Tongue Resting Position
Yes
No
Family History
Pre-Treatment Recommendation:
Speech Pathologist Date
DD slash MM slash YYYY
Dentist Date of Release
DD slash MM slash YYYY
Dentist Date of Release
DD slash MM slash YYYY
Referring Practitioner Comments
Referring Practitioner Comments
74172
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