Intake form

Help us serve you better

Name *

Email address *

What is your age?

What is your primary concern regarding your oral and facial function?

Please select at least one option.

Breathing issues

Swallowing difficulties

Chewing problems

Speech issues

Sleep-related issues

Have you received any previous myofunctional therapy?

Do you have any existing medical conditions?

What medications are you currently taking?

Do you have any allergies?

How did you hear about mind body myo?

What days and times are you generally available for appointments?

Additional questions or comments

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Mind Body Myo