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Myofunctional Examination Informed Consent & Cancellation Policy

Full Name

Welcome to Mind Body Myo.

Before your exam, please take a few minutes to review the following information so you know exactly what to expect.

Purpose of the Examination

The myofunctional exam is designed to assess how your lips, tongue, jaw, and breathing work together. During this visit, we’ll look at posture, muscle balance, swallowing patterns, and oral habits to understand the root causes of your concerns.

The goal is to help determine whether myofunctional therapy would be beneficial and, if so, to outline a personalized plan of care. This exam is educational and therapeutic in nature and does not replace medical or dental treatment.

Your exam may include:

- Visual and functional assessment of the orofacial muscles

- Review of breathing and swallowing patterns

- Discussion of your history, symptoms, and goals

- Photos or short videos (with your permission) for clinical documentation

- Recommendations for next steps, therapy, or referrals if appropriate

- This session will be conducted and recorded on Zoom. Recordings are used solely for review by the therapist to reference specific clinical indicators relevant to your care and to support the continued improvement of exam delivery and professional development. Recordings are stored securely and are not shared outside of Mind Body Myo LLC.

Exam Fee & Payment

- The exam fee is $175, due in full on the day of your appointment.

- Payment is accepted via zelle or credit card through Stripe

- A secure payment link will be sent to you on the day of your exam

- Checks or cash may also be mailed in advance if preferred.

Cancellation & Rescheduling Policy

Life happens, and we understand schedules can change. Out of respect for everyone’s time, please note the following:

- Cancellations or reschedules require at least 24 hours’ notice.

- Appointments cancelled with less than 24 hours’ notice will incur a $50 short-notice fee.

- No-shows or same-day cancellations (less than 2 hours before your appointment or failure to attend) will be charged the full exam fee ($175).

- Repeated short-notice cancellations may require prepayment for future bookings.

- Exceptions may be made at the discretion of Mind Body Myo LLC for emergencies or unforeseen situations.

Lighting & Setup

Please ensure you are in a well-lit space where your face, head, and shoulders can be clearly seen. You’ll need a laptop or desktop computer with a stable internet connection. If using a phone or tablet, it must be hands-free and positioned securely. Please have your phone flash light and a glass of water nearby for part of the exam.

Acknowledgment & Consent

By signing below, you acknowledge that:

- You have read and understood the information provided above.

- You understand the purpose and scope of the examination.

- You agree to the payment and cancellation policies as outlined.