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Patient First Name

Patient Last Name

Patient Preferred Contact Info

Provider's Name

Office Email Address

Pediatric Concerns:

Adult Concerns:

Night Sweats

Snores

Bed Wetting

Snoring

Jaw Pain

Facial Pain

Mouth Breathing

Headache

Night Terrors

Daytime Sleepiness

Restless

Voiding at Night (Noctume)

Hyperactive

Insomnia

Crowded Teeth

Non-Restorative Sleep

Grinds Teeth

Difficulty Focusing

Irritable

Anxiety / Depression

Speech

Clenching or Grinding

Restricted or Scalloped Tongue

Underdeveloped Maxila and/or Mandible

Tongue or Lip Tie

Difficulty Opening

Other:

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Ear Pain

Jaw Locking

Mairelated Arches

Other:

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HOME
ABOUT US
TREATMENT
NEW PATIENT FORMS
CONTACT
BOOK ONLINE
REFER A PATIENT

CONTACT US

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P. 919-769-2999
E. info@developmentaldentistry.com
Developmental Dentistry

5317 Highgate Dr # 118,

Durham, NC 27713