Referral for Oral Dysfunction Form - DentalCareXtra

Ensuring the best possible outcomes for our patients

Practitioner Name(Required)
If you are not the above Practitioner please complete your name below.

Patient Details

DD slash MM slash YYYY
Guardian's Name(Required)


Incorrect Swallow Pattern
Learning Difficulties
Colic Symptoms
Incorrect Chewing Patterns
Narrow Upper Arch
Communication Difficulties
Poor Lip Competence
Cross Bite
Feeding Swallowing Difficulties
Crowded Teeth
Mouth Breathing
Low Tone
TMJ Dysfunction
Poor Head Control
Poor Posture
TMJ Dysfunction
Incorrect Tongue Resting Position

Pre-Treatment Recommendation:

DD slash MM slash YYYY
DD slash MM slash YYYY
DD slash MM slash YYYY

Referring Practitioner Comments