Craniofacial Headaches Migraine Pain Diagnosis and Treatment

Use this form to request specific assistance in having a Treatment Specialist located and requested to contact you for obtaining a professional consult and assessing the potential benefit for treatment.

Please provide as much detail as necessary to assure an accurate referral. Your private information is discarded (not kept for any purpose) after the referral is completed.

First name:		Last Name:
Address:
City, ST, Zip:
Email:
Telephone:		Time to Call:

History

Months of discomfort:
Months of treatment:
Taking Medications now?:		Yes No
Have you had MRI's done?:		Yes No
Have you had CAT Scans?:		Yes No
Have you had a Tomogram?:		Yes No
Have you used appliances?:		Yes No
If you have used or are currently using appliances (mouthguards, splints, etc.) please indicate type here:
Distance you are willing to travel for effective treatment:

Please add other comments below

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