New patient forms
The Myobrace Centre
Step 1 of 5 · About the patient
Patient information

Let's start with your child's details

Please complete these forms before your child's first appointment — it takes about 6–8 minutes, and your answers go straight to our clinical team.

Contact details

We'll use this to confirm appointments and share information about treatment.

Health fund

Please complete the highlighted fields to continue.
Your visit

A little about why you're here

This helps us understand what matters most to you before the first appointment.

What is the reason for visiting The Myobrace Centre?

Tick all that apply.

Does the patient have any of the following health problems?

Tick all that apply — you can give more detail in the medical history step.

How did you hear about Myobrace®?

Previous advice

Have you ever spoken to a Dentist or Orthodontist about treatment options prior to today?
Has a Dentist or Orthodontist informed you about Early Orthodontic Treatment, Myofunctional Orthodontics or any other orthodontic options prior to today?

Referred by a health professional?

Name of referrer — fill in any that apply.

Would you like us to inform either professional of your treatment?

Please note: if you choose Dentist or Doctor above, it is your responsibility to let us know if your practitioner changes.

Please answer the highlighted questions to continue.
Patient medical history

Your child's medical history

Answer Yes or No — where you answer Yes, a box will appear so you can add details.

Sleep symptoms

Does the patient have any of the following sleep symptoms?

TMD (jaw joint) symptoms

Conditions

Please tell us about any conditions the patient has now, or has had in the past. Leave blank if none.

Please answer the highlighted questions to continue.
Myosleep Kids questionnaire

How does your child sleep?

Answer based on your child's average sleep habits over the past month. If you're unsure about an answer, choose the ? option.

1 · Going to sleep4 QUESTIONS
2 · While sleeping11 QUESTIONS
3 · While awake14 QUESTIONS
A few questions were missed — they're highlighted above. If you're unsure, choose “?”.
Review & sign

Almost done — please sign below

Signing for: — · Date: —

I have truthfully answered all the above questions and agree to inform this clinic of any changes in my medical or dental history. In addition, I authorise The Myobrace Centre® to perform a complete Dental, Orthodontic and/or TMJ evaluation. This signature also applies to my answers in the Myosleep Kids questionnaire.
Sign here with your finger or mouse
Draw your signature in the box.
Please tick the declaration, add your name and sign in the box.

All done — thank you!

Your forms have been sent to the clinic. We look forward to seeing you at your appointment.

In the print window, choose “Save as PDF”.

This form is confidential and is used by the clinic to plan your child's care.
If you'd rather complete a paper copy, just let our reception team know.