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Deep Teeth Cleaning
Gum Disease Laser Therapy
Periodontal Maintenance
Arestin
Dental Sealants
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Laser Smile
Zoom Whitening
Inlays & Onlays
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Deep Teeth Cleaning
Gum Disease Laser Therapy
Periodontal Maintenance
AI-Assisted Skin Analysis
Hair Restoration
PDO Smooth Threads
Potenza RF Microneedling
Rebase And Repairs
Exams & Maintenance
Relines
Soft Liners
TMJ
Alma CBD Skincare
LMNT Red Light Therapy
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Skin Resurfacing
Skin Rejuvenation
Laser Hair Removal
Dermal Fillers
Botox Cosmetic
Sleep Apnea
Partial Dentures
Implant Retained Dentures
Immediate Dentures
Denture Care
Full Mouth Rehabilitation
Non Surgical Root Canals
Tooth Extractions
Dental Crowns
Dental Fillings
Dental Implants
Dental Bridges
Arestin
Dental Sealants
Children's Dentistry
Oral Hygiene
Teeth Cleaning & Dental Checkups
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Laser Smile
Zoom Whitening
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Online Referral Form
Referral Form: Orofacial Pain, TMJ, & Sleep Apnea
Name:
Date:
Office:
Phone Number:
Email Address:
Would like a call:
Not Necessary
Before Evaluation
After
Patient Name:
DOB:
Patient Phone Number:
Patient Email Address:
Please Evaluate and Treat:
Clicking / Popping in TMJ
Neck / Shoulder Pains
Snoring
Pain with Opening / Chewing
Ear Pain / Tinnitus
Sleep Apnea
Changes in Occlusion
Teeth Grinding
Orofacial Pain
Headaches / Migraines
Locked Jaw
Additional Notes:
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