Medical History for Orofacial Myology Consultation

The following questions are only for Orofacial Myology appointments. Please be brief.

Please complete the below medical history information ONLY IF REQUESTED TO DO SO as soon as you have made a booking or at least 24 hours prior to your appointment.

* = mandatory response required

Please correct the following errors before submitting the form again.
THIS INFORMATION IS ABOUT YOUR CHILD: