Chicago Myo | SimplePractice

Chicago Myo Send Message

Your info

First name

Last name

Email

Phone

Who is this care for?

the person who will receive therapy

Myself My child Someone else

If you are completing this form for someone else, please provide their full name.

e.g., Jane Doe. Leave blank if this care is for you.

Date of birth of the person who will receive therapy

MM/DD/YYYY

Reason for care

What is the reason for seeking care?

Orofacial Myofunctional Therapy (OMT) Tongue Tie (Pre- or Post- Release) Sleep / Snoring / Mouth Breathing TMJ / Clenching / Grinding Orthodontic Support / Relapse Articulation / Speech Sounds Feeding / Picky Eating Not sure - I'd like to discuss

Tell us a bit more about your concerns

Limited to 600 characters

Administrative

How did you hear about us?

Dentist or orthodontist Physician (ENT, sleep, pediatrician) Friend or family member Online search (Google, etc.) Social media Other

If a provider referred you, who can we thank?

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.