Referral Form

Screening Form

For patients with head, neck and facial pain & sleep-disordered breathing/apnea

    Primary headaches or migrainesSnoring/Sleep ApneaDisturbed, restless sleepingCPAP intoleranceAttention deficit in children

    Ear aches, stuffiness, ringing or dizzinessNeck, shoulder, back pain or stiffnessPain or soreness in TM jointsClicking or grating sounds in TM jointsLimited mouth openingLocking jaw (opened or closed)

    When your patients experience one or more of these symptoms, they should have a thorough evaluation by a dentist trained in TMD and Sleep. We will be happy to assist you in diagnosis and treatment for possible crandiomandibular/temporomandibular dysfunction or sleep-disordered breathing/apnea.

    Patient Information:

    Referred By: