New patient intake

Tell us a little about your child before your first visit.

This helps us prepare a thoughtful assessment. Only the fields marked with * are required — share as much or as little as you like on the rest.

Patient details

Patient name*Age*Filled out by

Contact

Email*Phone

Preferred contact method*

EmailPhone callText / SMSWhatsApp

Best time to reach you

Session preference

No preferenceIn-personVirtual

How did you hear about us?

Instagram / FacebookGoogle searchReferral from dentist / orthodontistReferral from ENT / doctorFriend or familyOther

Concerns

Primary reason for booking*

ENT concerns (tick any that apply)

Enlarged tonsils / adenoidsChronic mouth breathingRecurrent congestion / allergiesFrequent ear infectionsDeviated septumDifficulty swallowing

Orthodontic concerns

Crowded teethNarrow palateOpen biteCrossbiteCurrently in braces / alignersWearing an appliance (B-Bite, Myobrace, expander)Relapse after previous ortho

Breathing & sleep

SnoringMouth open at nightRestless sleepDaytime fatigueDiagnosed sleep apnea

Oral habits

Thumb / finger suckingPacifier useTongue thrustNail bitingTeeth grinding / clenching

History

Current treatments or appliances

Previous ENT treatment (tonsils/adenoids, tubes, surgery)

Allergies & current medications

Anything else we should know

Goals

What would you like to work towards? (tick any that apply)

Nose breathing throughout the dayLips gently together at restTongue resting on the roof of the mouthBetter, more settled sleepLess snoring / mouth breathing at nightCalmer focus and behaviourImproved eating / swallowingSupport orthodontic / appliance treatmentReduce thumb sucking / oral habitsReduce teeth grinding / jaw tension

Other goals / anything else you'd like to achieve

Data protection notice

The information you provide is used only to assess and arrange your care. We handle it in line with UK GDPR law, keep it secure, and do not share it with anyone outside your care team without your consent. By submitting this form, you agree to our Privacy Policy, Terms of Use and Disclaimer.

Myo with Miss Hiral