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First name
Last name
Email
Phone
Child's Name
Select symptoms that apply:
Articulation problems
Dental abnormalities
Drooling/poor oral control (ages 2+)
Mouth breathing
Open mouth posture
Orthodontic issues
Picky eating habits
Problems with chewing/swallowing
Sleep issues
Teeth grinding/TMD
Finger/Thumb/Tongue sucking
Tongue thrust
Tethered oral tissues
Child's Age
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