Forms

Below is a compilation of informational forms, questionnaires, and instruction sheets used at Revive. For new patients, please feel free to print out the Patient Information form, HIPAA Compliance form, and the Revive Questionnaire and bring them with you to your consultation. Generally, a diagnosis can not be made by simply taking a questionnaire, so please set-up a consultation if you suspect you need treatment.
  • PATIENT INFORMATION

    Patient Information form

  • MYOFUNCTIONAL EXERCISES

    Bi-weekly Orofacial Myofunctional Therapy Exercise sheet

  • CREDIT CARD AUTHORIZATION 

    Credit Card Authorization form

  • HIPAA

    HIPAA Compliance form

  • REVIVE QUESTIONNAIRE

    Short patient screening questionnaire

  • SLEEP DISORDER 

    Sleep Disorder Questionnaire

  • COMPREHENSIVE SLEEP

    Comprehensive Sleep Questionnaire 

  • EPWORTH

    Epworth Sleepiness Scale

  • MYOFUNCTIONAL DISORDERS

    List of common orofacial myofunctional disorders

  • MYOFUNCTIONAL FAQ'S

    List of frequently asked questions regarding orofacial myofunctional therapy

  • FRENECTOMY POST-OP

    Home care instructions after frenectomy

  • APPLIANCE CARE

    Home care instructions on cleaning/caring for your appliance

  • BOTOX THERAPY

    Home care instructions before and after Botox or Xeomin therapy

Monday: 10am - 6pm

Wednesday: 12pm - 8pm​​

​Saturday: 9am - 1pm

Online Therapy Sessions Available!

500 N. Rainbow Blvd, Ste. 315

Las Vegas, NV 89107

Located inside Valley Smile Solutions

revivegrowsleepbreathe@gmail.com

Tel: 702-763-7429

© 2020 by Revive Orofacial Therapy and Wellness Center