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Patient Referral

About
Airway Services
Dr. Graham & Team
Patient Referral
Resources
Contact

About
Airway Services
Dr. Graham & Team
Patient Referral
Resources
Contact

About
Airway Services
Dr. Graham & Team
Resources
Patient Referral
Request a Live Webinar
Contact

About
Airway Services
Dr. Graham & Team
Resources
Patient Referral
Request a Live Webinar
Contact

Patient ReferralDr. Meggie Graham
2524 E Webster Pl. Suite 201A
Milwaukee, WI 53211

View the 6 Red Flags for Pediatric Sleep Disordered Breathing (SDB)

View PDF

Patient Name*

Parent Name

Patient's DOB

Today's Date

Cell Phone Number*

Email Address*

Referring Office (include contact info)

Referring Office Email

What practitioner is the referral for? (select all that apply)

Meggie Graham, Airway-focused Dentist Tony Rieder, ENT, Sleep Physician Orofacial Myofunctional Therapist Baby Feeding Specialist - Julia Clayton or Jordan Beck

Will your office send any diagnostic imaging (photos, radiographs, CBCT) ahead of patient's consult? If so, please upload them below.

Yes No

Upload All Files Here (accepted file types: jpg, jpeg, gif, png, pdf, doc, docx):

Reason for Referral

INFANT

Mouth Breathing Weight Problems Fusses/Slips off Breast Continuous or Frequent Feeds Excessively Gassy / Reflux Dribbles Out Large Amounts of Milk Tongue-Tie (Lingual Frenulum) Lip-Tie (Labial Frenulum) Oral Motor Dysfunction Sleep Hygiene Other

PEDIATRIC/ADULT

Mouth Breathing Dental Crowding Tongue-Tie (Lingual Frenulum) Lip-Tie (Labial Frenulum) Sleep Hygiene Bruxism/Clenching Speech Issues Noxious Oral Habits (thumb/digit sucking, pacifier usage, etc.) Orthodontics Difficulty Swallowing At Home Sleep Study CPAPA Intolerance/Failure Upper Airway Resistance Syndrome Snoring/Sleep Apnea Chronic Fatigue TMJ/TMD Pain Craniofacial Pain Headaches/Migraines Myofunctional Therapy Maxillary Expansion Other

MATERNAL ASSESSMENT

Sore Engorgement/Blocked Ducts/Mastitis Low Milk Supply Other

Additional Information (for Tongue-Tie Patients)

Has the patient already begun Myofunctional Therapy?

Yes No

Any limitations/challenges in doing therapy?

Any other providers invloved in this patients’ care? (orthodontist, bodyworkers, myofunctional therapists, etc?)

Any additional notes regarding your patient?

OUR Hours

MONDAY:
8:00 am – 5:00 pm

TUESDAY:
8:00 am – 3:00 pm

WEDNESDAY:
8:00 am – 3:00 pm

THURSDAY:
8:00 am – 3:00 pm

FRIDAY:
BY APPOINTMENT ONLY

SATURDAY:
Closed

SUNDAY:
Closed

ADDRESS

2524 E. Webster Pl #201A

Milwaukee, WI 53211

CONTACT

hello@untetheredttc.com

414-935-8460 (text or call)

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