(205) 874-9699
Sleep
Sleep Apnea
Sleep Questionnaire
Sleep Tips
Pain
TMJ
Headache
Myofascial Pain
Neuropathic Pain
Pain Tips
Meet Our Team
Contact Us
Sleep
Sleep Apnea
Sleep Questionnaire
Sleep Tips
Pain
TMJ
Headache
Myofascial Pain
Neuropathic Pain
Pain Tips
Meet Our Team
Contact Us
Referrals
Introducing :
*
Referring Doctor :
*
Doctor's Phone
Doctor's Fax
*
Patients's Phone
*
Date
*
Date Format: MM slash DD slash YYYY
Select One of the Following
*
Please call patient to schedule appointment
Patient will call to schedule their appointment
Signs & Symptoms of Pain
Earaches, Fullness or Ringing
Clicking or Grating Sounds in TMJ
Pain or Soreness in TMJ
Locked Jaw
Neck, Shoulder, Back Pain or Stiffness
Dizziness / Vertigo
Headaches / Migraines
Pain Behind Eyes
Unexplained Teeth or Facial Pain
Limited Mouth Opening
Other
NONE
If Other, Please Specify :
Sleep Apnea / Snoring
Sleep Apnea
Bruxism
Snoring
None
Consent
*
I agree to provide patient with any current images and bloodwork.
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