Smile quiz

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We've updated our form! Click here to get booked in to see Dr. Semaan at Clear Smiles Orthodontics
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Welcome to Clear Smiles Orthodontics, let's start with your name* This field is required.
First Name
Last Name
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Hello {welcomeTo:first}, is the consultation for:* This field is required.
You
Your child
More than one child
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Hi {welcomeTo},

Please take your time to read below to understand our processes for mutiple bookings.

Our smile assessment is an integral process used to best prepare everyone for an orthodontic consultation. So we can ensure we reserve enough time to best serve each of your children to their specific smile needs, please complete a separate smile assessment for each child you are wanting to book a consultation for.

We do appreciate that it makes sense to place siblings or multiple bookings made by one parent in back to back appointments but Dr Semaan’s availability doesn't always allow for this. When scheduling an appointment please choose the two closest times possible. If your child is under a certain age your only available times will be shown as 10.00am and 3.00pm. Our team will work to put these appointments together but we cannot guarantee this will be the case in every situation.

Please expect a phone call or message from one of our team members who may be able to reshuffle our availability and times to produce the best outcome.

Please press next and complete the first assessment and then return to complete the second assessment and so on for the number of children you're making appointments for.
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Your Child's full name
First Name
Last Name
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GenderWe only ask so when you arrive for your consultation there's absolutely no confusion whatsoever, but by all means feel free to skip this question :)
Male
Female
I'd prefer not to say
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{yourChilds}'s genderWe only ask so when you arrive for your consultation there's absolutely no confusion whatsoever, but by all means feel free to skip this question :)
Male
Female
I'd prefer not to say
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What's your D.O.B* This field is required.(So we can tailor treatment options that are right for you)
Date
Day
Month
Year
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What's {yourChilds}'s D.O.B* This field is required.(So we can tailor treatment options that are right for them)
Date
Day
Month
Year
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Parent/Guardians full name As you are under 18 please enter your responsible parties details
First Name
Last Name
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Current Date
Date
Day
Month
Year
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Age
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Age (1) for Adult verification
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Why are you thinking about straightening your teeth {typeA81}?* This field is required.
1. I have been referred by a dentist
2. I'd like generally straighter teeth
3. I want to feel more confident
4. I've got a special occasion coming up
5. I want a second opinion
6. To improve my general oral health
7. I want to transfer my current treatment
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Why is {yourChilds} thinking about straightening their teeth?* This field is required.
1. We have been referred by a dentist
2. They'd like generally straighter teeth
3. They want to feel more confident
4. I want a second opinion
5. To improve their general oral health
6. I want to transfer their current treatment
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{yourChilds} has qualified for Dr Semaan's photos at home program!

Please read the below carefully and follow the instructions to send photos in

88% of children who see an orthodontist between the ages of 7 and 11, don't require any early interceptive orthodontic treatment.

Our solution is for you to take photos from home. An easy, free, and extremely accessible tool to give you the chance to have a specialist see your child at the right time.

How it works:

Follow the instructions at the bottom of this document and you'll be asked to upload the required 6 images on the next page

Dr Seeman will freely assess your child's smile and bite

We'll let you know whether your child requires urgent orthodontic treatment or if they can wait

If necessary orthodontic treatment is required, we'll secure you an in-person consult to discuss {yourChilds82}'s treatment options

If your child can wait, you'll automatically qualify and be added to our Family Care Program

Family Care Program:

Our family care program places your child onto a routine monitoring schedule, where we prompt you to send photos in every 3-6 months. Dr Semaan believes every child deserves the option of early interceptive orthodontic treatment but we can save you time and money by only having you and your child come into our clinic when the time is right.

Instructions:
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Upload the 6 images here for Dr Semaan to review* This field is required.Go back to see instructions on how to take photos
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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How would you rate your smile?
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
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How would you rate {yourChilds}'s smile?
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
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Which best describes your smile?
Crooked teeth
Gap teeth
Narrow smile
Overbite
Open bite
Under bite
Crowded
Something else
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Which best describes {yourChilds}'s smile?
Crooked teeth
Gap teeth
Narrow smile
Overbite
Open bite
Under bite
Crowded
Something else
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Try your best to describe your smile* This field is required.Don't worry, we've heard it all before, and there's no silly answers!
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Your Dentist's details* This field is required.
Dentist's name
Dental practice name
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What has {yourDentists[3]} referred you for?
Crooked teeth
Gap teeth
Narrow smile
Overbite
Open bite
Under bite
Crowded
CT Scan/iTero Scan
Other/Referral notes
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What has {yourDentists[3]} referred {yourChilds} for?
Crooked teeth
Gap teeth
Narrow smile
Overbite
Open bite
Under bite
Crowded
CT Scan/iTero Scan
Other/Referral notes
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Thank you for requesting to transfer your treatment to Clear Smiles Orthodontics. Please read the below before pressing next.

1.Following the submission of this form you will be sent an email with a URL link to our transfer application form. You are required to have your previous orthodontist/dentist complete this application on your behalf.

2.You will be notified by email once your previous orthodontist/dentist has submitted the application to us.

3.From there Dr Semaan will review your application.

4.Should your application be accepted we will contact you to book an initial consultation. Please note we do not accept all applications and reserve the right to decline. Should this be the case we will let you know why your application has been declined.

The Clear Smiles Orthodontics team!
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IMPORTANT! You are seeing this screen because you have selected CT Scan/iTero Scan as a referral note. If you have been referred for more than just a scan please click 'PREVIOUS' and unselect. If you have been referred only for a CT Scan or iTero Scan please read below and continue.

Thank you for requesting a CT Scan/iTero appointment. As this is a highly specialised appointment request we do not offer online bookings for this service. Please expect a phone call to the number you provide to us on the next screen. One of our friendly team will find and be able to secure you our next available CT Scan/iTero appointment.

The Clear Smiles Team!
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Please supply further detail belowyou can even copy exactly what your dentist may have written down
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If you a had an X-ray taken at your recent dental visit you can:1. Attach this here ┃2. Email to admin@clearsmilesorthodontics.com.au ┃ 3. Bring a physical copy to your consultation ┃4. Have us take another X-ray, free of charge for Medicare Card holders
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Contact details* This field is required.
Mobile number
Please enter your email
Please provide your residential address
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Have you had orthodontic treatment previously?* This field is required.
Yes
No
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Has {yourChilds} had orthodontic treatment previously?* This field is required.
Yes
No
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Please specify from the following:
Braces
Clear Aligners
Tooth removed
Other
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How long has it been since you have finished treatment?
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Do you have any outstanding dental work that needs completing?* This field is required.
Yes
No
I don't know
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Does {yourChilds} have any outstanding dental work that needs completing?* This field is required.
Yes
No
I don't know
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Please specify from the following:
General clean
Root canal treatment
Teeth extractions
Fillings
Crowns
Other
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If you a had an X-ray taken at a recent dental visit you can1. Attach this here ┃2. Email to admin@clearsmilesorthodontics.com.au ┃ 3. Bring a physical copy to your consultation ┃4. Have us take another X-ray, free of charge for Medicare Card holders
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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How long has it been since you last saw your dentist?
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Place in order what matters to you mostDrag and drop to change order (1= very important 4= least important)
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When it comes to clear aligners, are you?* This field is required.
Informed- I've done my research
Curious- I know a bit and want to learn more
Skeptical- It's too good to be true
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What is your expected cost of treatment?* This field is required.
$5,000-$7,000
$7,000-$9,000
$9,000-$11,000
$11,000+
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Bang on! Great guess
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Not quite right!
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Do you have access to Private Health Insurance?* This field is required.*Please note, without a Private health fund card or Australian Government Medicare Card a $100 fee will apply to the consultation for the required X-ray
Yes
No
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Does your Private Health insurance cover orthodontics?
Yes
No
I don't know
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Have you had a consultation with Clear Smiles Orthodontics before?* This field is required.
Yes
No
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Has {yourChilds} had a consultation with Clear Smiles Orthodontics before?* This field is required.
Yes
No
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New Patient Child Appointment* This field is required.Please note these are the only available times to see our specialist Dr Semaan. By clicking submit you are agreeing with our Privacy Policy found https://www.clearsmilesorthodontics.com.au/privacy-policy/
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How did you hear about us?* This field is required.
Google
Facebook
Instagram
You emailed me
Family & Friends
Your website
None of the above
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Please provide the full name of the friend/family who referred you(You could be eligible for a family/referral discount)
First Name
Last Name
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Promo codeEnter promo code if applicable, press next if not!
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New Patient Appointment* This field is required.Make sure a time is highlighted in blue before submitting. Please note these are the only available times to see our specialist Dr Semaan. By clicking submit you are agreeing with our Privacy Policy found https://www.clearsmilesorthodontics.com.au/privacy-policy/
Should be Empty:

{yourChilds} has qualified for Dr Semaan's photos at home program!

How it works:

Family Care Program:

Instructions: