Child Self Referral Form

Your Details

• Full Name *
• Child's Name *
• Email Address *
• Telephone Home Mobile Work

Your Child's Teeth

Select as many as appropriate

• A bit of crowding

  A lot of crowding

  Front teeth sticking out

  Lower teeth in front of upper

  Gaps show between teeth

  Worn teeth

  Twisted tooth / teeth

  Uncomfortable bite

  Discoloured tooth

  Upper teeth overlap too much

  Upper & lower front teeth don't overlap

  Teeth off-centre

  Teeth moving

Your Child's Facial Appearance

Select as many as appropriate

• Lower jaw sticks out

  Lower jaw a bit small

  Too much gum shows when smiling

  Upper teeth don't show when smiling

  Upper jaw a bit narrow

  Smile a bit narrow

  Lips don't meet when relaxed

  Lower lip curls when mouth is closed

  My child's face is lopsided

Lifetime Healthy Bite & Fabulous Smile

All children will be recommended the best treatment option for a lifetime healthy bite and a fabulous smile. Please tick if you are especially interested in any of the following additional options

• Cosmetic fixed braces

  Inside braces (Incognito)

  Clear removable (Invisalign Teen)

  Accelerated treatment (AcceleDent)

  Damon braces

How did you hear about us?

Select as many as appropriate

• Your dentist

  A friend

  A family member

  A website (please specify below)

  An advert (please specify below)

  Other (please specify below)

  Please specify

Please tell us, in your own words, what you would like to see improved about your child's smile?

Do you have a particular event or deadline that you want treatment finished by?