For professionals

Refer a patient for myofunctional therapy.

Dentists, orthodontists, ENTs, GPs, speech & language therapists and other professionals — share the patient’s details and reason for referral, and we’ll take it from there. Only the fields marked with * are required.

Your details

Your name*Role / profession*Practice / organisationEmail*Phone

Patient details

Patient name*Age*Parent / guardian (if a child)Patient / guardian emailPatient / guardian phone

Is the patient (or guardian) aware of this referral?*

YesNot yet

Reason for referral

Reason for referral*

Concerns (tick any that apply)

Mouth breathing / poor nasal breathingSleep issues / snoringTongue thrust / swallowing patternOral habits (thumb sucking, pacifier)Orthodontic support / relapse preventionSpeech or feeding difficultiesTMJ / jaw tension or grindingTongue-tie (pre/post release care)

Current treatment & history

Current treatment or appliances

Relevant medical / dental history

Goals & anything else

Goals for therapy

Any other relevant information

Data protection notice

The information you provide is used only to assess and arrange the patient’s care. We handle it in line with UK GDPR law, keep it secure, and do not share it with anyone outside the care team without consent. Please ensure you have the patient’s (or guardian’s) permission to share their details. By submitting this form, you agree to our Privacy Policy, Terms of Use and Disclaimer.

Myo with Miss Hiral

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