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260-387-6670Patient Portal Doctor Portal

TMJ & Sleep Therapy Centre of Fort Wayne

Craniofacial pain, Snoring and Sleep Apnea Relief

Our Practice
TMD/Head & Facial Pain
Sleep Disorders
Pediatrics
- Pediatric TMD/Head & Facial Pain
- Pediatric Sleep Disorders
Tongue Tie Release/Frenectomy
Healthy Living

Request Appointment

Our Practice
TMD/Head & Facial Pain
Sleep Disorders
Pediatrics
- Pediatric TMD/Head & Facial Pain
- Pediatric Sleep Disorders
Tongue Tie Release/Frenectomy
Healthy Living

Referring Patients

Referring Patients

This form is for doctors to refer their patients to our practice for treatment with TMD and Sleep Apnea issues.

Patient Name*
First Last
Patient Phone Number*
Patient Email (Optional)
Patient Address*
Street Address Address Line 2 City State ZIP Code
Patient's Birth Date
MM slash DD slash YYYY
Referred by:*
Referring Doctor's Phone*
Referring Doctor's Fax
Referral needs:*
- Exam
- 2nd Opinion
- Send Report
- Call Me
- Other
"Other" explanation
The following symptoms were noted:
- Primary headaches or migraines
- Snoring/Sleep Apnea
- Disturbed, restless sleeping
- CPAP Intolerance
- Fatigue/Daytime Drowsiness
- Attention deficit in children
- Earaches, stuffiness or ringing
- Neck, shoulder, back pain or stiffness
- Dizziness
- Pain or soreness in TM joints
- Clicking or grating sounds in TM joint
- Limited mouth opening
- Locking jaw (open or closed)
- Facial or undiagnosed teeth pain
- Difficulty swallowing
Upon evaluation, if your patients experience one or more of the symptoms below, they should have a thorough evaluation by a dentist trained in TMJ & Sleep. We will be happy to assist you in the diagnosis and treatment of Craniofacial Pain, Headaches, TMD, or Sleep Disordered Breathing/Apnea.
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DOCTOR PORTAL

REFERRING PATIENTS

CONTACT US

260-387-6670

877-410-0567

9121 Illinois Rd
Fort Wayne, IN 46804

OFFICE HOURS

TUESDAY	8:00 AM - 5:00 PM
WEDNESDAY	8:00 AM - 5:00 PM
THURSDAY	8:00 AM - 5:00 PM
FRI - MON	CLOSED

Additional Links

Home
Meet The Practice
TMD/Head & Facial Pain
Sleep Disorders
Pediatrics
Tongue Tie Release/Frenectomy
Patient Portal
Contact Us

9914 Illinois Rd. Fort Wayne, IN 46804

260-387-6670

REQUEST APPOINTMENT

OFFICE HOURS

MONDAY	CLOSED
TUESDAY	8:00 AM - 5:00 PM
WEDNESDAY	8:00 AM - 5:00 PM
THURSDAY	8:00 AM - 5:00 PM
FRIDAY	CLOSED
SATURDAY	CLOSED
SUNDAY	CLOSED

Additional Links

Home
Meet The Practice
TMD/Head & Facial Pain
Sleep Disorders
Pediatrics
Tongue Tie Release/Frenectomy
Patient Portal
Contact Us

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