TMD & Orofacial Pain Referral

I. Patient Information

Patient's Legal Name: required

Patient Email Address: required

Patient Phone Number(s):

Referring Clinician Information: required

* No patients will be accepted for general dentistry

* All services performed by a general dentist

TMD/TMJ Issues

Migraines or Other Headaches

Sleep Dentistry, MADs and Oral Appliance Therapy

Neuropathic Pain or other Oral Pain

Other

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