Date:
Introducing: Pho
ne:
Referred by: Phone:
Fax:
FOR: P
ROBLEM:
Diagnosis & Treatment Facial Pain
Diagnosis Only Tooth Pain
Second Opinion Headache
TMJ
Bite Shifting
Snoring /
Sleep Apnea
Bruxism / Orofacial
Dystonia
Area of Concern:
Comments:
A letter detailing the findings on your patient will be sent to you after your patient is seen. Please make
a special note if you would like a phone call regarding your patient. New patient evaluations are
typically 90 minutes.