Myobrace® Pre-Questionnaire | Smile Studio Newstead

NEW PATIENT PROMOTION
$500-$1000 Off Invisalign Treatment.* T&C’s apply.
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NEW PATIENT PROMOTION | $500-$1000 Off Invisalign Treatment.* T&C’s apply.

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THE FIRST STEP ON YOUR SMILE JOURNEY

Myobrace Pre-Questionnaire

We are looking forward to meeting you very soon to discuss your child’s smile. To help us understand your concerns, we hope you can spare a moment to return this questionnaire with as much detail as possible.

Fill Out Form

Dentist Newstead > Myobrace Pre-Questionnaire

Parent's Full Name

Your Child's Full Name

Have you heard of the Myobrace system before?

Yes No

Does your child have any of the following issues? If you select No, skip the Adjustments section and click Next.

Yes No

Do they have crooked teeth?

Yes No

Are you concerned about their eating habits?

Yes No

Are they often tired and have difficulty concentrating?

Yes No

Do they sleep with their mouth open?

Yes No

Have they had dental fillings in the past?

Yes No

Do you hear them grinding their teeth when they are asleep?

Yes No

Is there a family history of sleep problems or orthodontics?

Yes No

Has your child had an orthodontic consultation previously?

Yes No

If yes, when? What was the recommendation?

Can they comfortably sit with their lips closed and breathe through their nose for 3 minutes?

Yes No

Feel free to look at Myobrace or our website for additional information about orthodontic treatment.
We look forward to seeing you soon,
Dr. Cate Gerber and The Smile Studio Newstead Team