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12425 55th St N Suite B
Lake Elmo, MN 55042
(651) 439-0322
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Refer a Myofunctional patient
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ABOUT
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SERVICES & PROCEDURES
ALL SERVICES
FAMILY DENTIST
COSMETIC DENTISTRY
TEETH WHITENING
INVISALIGN BRACES
CROWNS AND BRIDGES
DENTAL IMPLANTS
QUALITY DENTURES
GENERAL DENTISTRY
PREVENTIVE DENTISTRY
ROOT CANAL TREATMENT
TMJ THERAPY
VENEERS
ITERO SCANNING
MYOFUNCTIONAL THERAPY
ROUTINE DENTAL CLEANING
SMILE GALLERY
REVIEWS
PATIENT INFO
PATIENT INFO
YOUR FIRST VISIT
NEW PATIENT REGISTRATION FORMS
FAQS
FINANCIAL
CONTACT
Menu
HOME
ABOUT
OFFICE TOUR
BLOG
SERVICES & PROCEDURES
ALL SERVICES
FAMILY DENTIST
COSMETIC DENTISTRY
TEETH WHITENING
INVISALIGN BRACES
CROWNS AND BRIDGES
DENTAL IMPLANTS
QUALITY DENTURES
GENERAL DENTISTRY
PREVENTIVE DENTISTRY
ROOT CANAL TREATMENT
TMJ THERAPY
VENEERS
ITERO SCANNING
MYOFUNCTIONAL THERAPY
ROUTINE DENTAL CLEANING
SMILE GALLERY
REVIEWS
PATIENT INFO
PATIENT INFO
YOUR FIRST VISIT
NEW PATIENT REGISTRATION FORMS
FAQS
FINANCIAL
CONTACT
Online Referral
Alissa Maroney BSDH, OMT
12425 55th Street North, Ste B - Lake Elmo, MN 55042
Patient Name
DOB
Email
Phone Number
Responsible party
CONCERNS:
Mouth Breathing
Mouth Breathing
Resting Tongue Posture
Restricted Nasal Airway
Short Lingual Frenum
Short Labial Frenum
Speech Concerns
HAS THE PATIENT HAD ORTHODONTICS:
yes no
Yes
No
OCCLUSION:
yes no
Class I
Class II
Class III
HAS THE PATIENT HAD A SLEEP STUDY:
yes no
Yes
No
HAS THE PATIENT BEEN DIAGNOSED WITH:
Sleep Disorder Breathing
Sleep disorder Breathing
Sleep Apnea
None
DOES THE PATIENT USE A CPAP:
Yes no
Yes
No
Unable to Tolerate
Referred by:
Date
Submit