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    21 Beaumont Street
    Oxford
    OX1 2NA

New Patients, Pre First Consultation

By completing this Form, you’ll help us to ensure we’re best placed to help you fix your Orthodontic problems, when we meet you.
How did you hear about us?
Family/friend
Referral
Internet
Social Media
Other

1) What are your main concerns? Why have you contacted and arranged a consultation?

In your own words please explain / describe, what your main concerns are with your teeth & smile.

(You may use expressions like…”The problem I have with my teeth is…” or ”What I’m most unhappy with about my smile is…”

Looking at the images below, which do you feel best shows the problem(s) you are experiencing. Tick all that apply.
Crowding
Crowding
Space/Gaps
Space/Gaps
Overbite
Overbite
Under bite
Under bite
Open bite
Open bite
Deep bite
Deep bite
2) How do the issues you have explained and highlighted, currently impact/affect your life?*
I have difficulty cleaning my teeth and maintaining good oral hygiene
I don’t like to smile in pictures or in social settings
I experience pain or discomfort when chewing or biting
I experience issues with my confidence and self-esteem
My teeth feel like they are being worn or damaged
Other

3) What do you hope Orthodontic Treatment will help you achieve?

*
My teeth will appear straighter
I will have improved bite and function
I will smile more easily
I will be able to maintain great oral health and hygiene 
I will feel more confident and positive
Other

4) Have you had orthodontic treatment in the past?

*
No
Yes
What Treatment option did you have?
Fixed braces
Removable aligners

5) What Orthodontic Treatment options would you like to have your Treatment with?

*
Removable clear aligners (Invisalign or Angel) 
Hidden fixed lingual braces (behind your teeth)
Clear / ceramic fixed braces
Not sure, I’d like to discuss options 

6) Do you feel there are any barriers to you starting Orthodontic Treatment now?

*
Treatment duration
Aesthetic concerns (appearance of braces)
Cost/payment options 
Comfort and potential pain 
Other

7) Are you ready and motivated to start Treatment?

*
YES, as soon as possible. I can’t wait to get to work on my new smile
NO

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