do or do not , there is no try check that box Patient's First Name * Patient's Last Name * Patient’s Age * If patient is a minor, parent’s name * Email * Patient's Phone * Reason For Referral * 3D CBCT Airway Assessment ALF therapy Babylase/Smilelase therapy Dual Wavelength Laser Frenectomy Forward Orthodontics General PediatricDentistry Growth Guidance Appliance Infant Assessment IV Sedation Myofunctional Therapy No Drill Laser Fillings Snoring/Nightlase Therapy Tooth Colored Crown Tooth Colored Filling Other If you answered (other) please list the reason here Current Therapies (i.e. speech, myofunctional therapy, orthodontics) Referring Provider * X-Rays or Forms X-Rays Forms Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use.