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Meet The Team
Dr. Jacqueline Patterson DDS OMT
Sleep Coordinator
Revive Services
Lingual and Labial Frenotomy
Jaw and Airway Development
Teeth Alignment
Oral Sleep Appliances
Craniofacial/TMJ Pain
Orofacial Myofunctional Therapy
Rejuvenation Services
For Practitioners
The Revive Approach
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Revive Resources
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MANY WAYS TO CONNECT YOUR PATIENTS/CLIENTS TO REVIVE
CLICK HERE FOR PRINTABLE REFERRAL FORM
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CLICK HERE TO REQUEST A REFERRAL PAD FOR YOUR OFFICE
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Complete Online Referral Form Below
Patient Referral Form
Patient First and Last Name
Guardian First and Last Name (if patient is under 18)
Email Address (Guardian's if applicable)
Cell Phone Number (Guardian's if applicable)
Referrer's Name, Office/Business Name, Email, and Phone Number
Please Select the Reason for Referral (Check All That Apply)
Thumb/Object Sucking
Nail Biting/Ice Chewing
Tongue Thrust/Open Bite
Obstructive Sleep Apnea
Child/Adolescent Bed Wetting
Crooked/Crowded Teeth
Underdeveloped Upper/Lower Jaw
Snoring
Tongue Tie/Lip Tie/Cheek Tie
Orthodontic Relapse
Sleep Study
Clenching/Grinding
Excessive Daytime Sleepiness
Hyperactivity/Trouble Focusing
Migraine/Headache
Mouth Breathing
TMJ Discomfort/Jaw Pain
Breastfeeding Difficulties
Neck/Shoulder Discomfort
Facial Aesthetic Services
Occupation of Referrer (Check All That Apply)
General Dentist
Orthodontist
Pediatric Dentist
Other Dental Specialty
Myofunctional Therapist
Dental Hygienist
Speech Language Pathologist
Physical Therapist
Occupational Therapist
Chiropractor
Massage Therapist
Sleep Physician
Pediatrician
ENT
Osteopath
Other Physician
Nurse Practitioner
Physicians Assistant
Registered Nurse
Lactation Consultant
Esthetician
Yoga/Breathing Instructor
Educator
Personal Injury Lawyer
Other
Has the Patient/Client Had a Craniofacial Panoramic Image or CBCT in the Last 6 Months?
Yes
No
Not Sure
Has the Patient/Client Had a Sleep Study Completed in the Last 6 Months?
Yes
No
Not Sure
Anything else you would like to add?
Submit Referral
We Appreciate Your Trust!
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