Toothpillow - Online Screening Form

1
You will need these 6 photos to complete your child's assessment. Pause now and take these photos and then come back and continue.When you have them saved on your device, click next
2
Who's the person we can thank for referring you?* This field is required.Please provide a specific name so that we can appropriately attribute credit to the individual who referred/shared with you.
3
Where do you live?* This field is required.(Currently ONLY accepting patients in the US)
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
New South Wales (AUS)
Queensland (AUS)
South Australia (AUS)
Tasmania (AUS)
Victoria (AUS)
Western Australia (AUS)
State
Zip / Post Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Patient's Name* This field is required.
First Name
Last Name
5
Patient's Age* This field is required.(Only accepting patients between the ages of 3-12)
6
Patient's Birthday* This field is required.
Date
Month
Day
Year
7
Patient Biological Gender
Male
Female
8
Parent/Guardian Name* This field is required.
First Name
Last Name
9
Parent/Guardian Email* This field is required.
example@example.com
10
Phone Number* This field is required.
Area Code
Phone Number
11
Text Messaging Opt-in* This field is required.We will primarily communicate with you via our secure Toothpillow smartphone app, but from time to time may use Text messaging which may not be fully secure. To consent, reply YES.
YESNO
12
What concerns do you have with your child's dental health?
Crooked teeth
Jaw development
Mouth breathing habits
Sucking habits
Other
13
Sleep and Breathing Questionnaire* This field is required.Please indicate if your child experiences or has experienced any of these symptoms below by using this scale to measure the severity of these symptoms.
Never
Rarely
Often
Always
Unknown
Snoring
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Labored, difficult or loud breathing at night
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Gasping for air while sleeping
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Mouth breathes while sleeping
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Mouth breathes during day
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Restless sleep
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Grinds teeth while sleeping
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Talks in sleep
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Excessive sweating while sleeping
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Wakes up at night
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Wets the bed (currently)
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
History of bed wetting
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Sleepy and/or irritable during the day
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Row 12, Column 4
Headaches
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Row 13, Column 4
Frequent throat infections
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Row 14, Column 4
Seasonal allergies
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Row 15, Column 3
Row 15, Column 4
Ear infections or history of ear infections
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Row 16, Column 3
Row 16, Column 4
Difficulty listening/ often interrupts
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Row 17, Column 3
Row 17, Column 4
Hyperactive
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Row 18, Column 3
Row 18, Column 4
ADD/ADHD
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
Row 19, Column 3
Row 19, Column 4
Sensory Issues
Row 20, Column 0
Row 20, Column 1
Row 20, Column 2
Row 20, Column 3
Row 20, Column 4
Speech Issues
Row 21, Column 0
Row 21, Column 1
Row 21, Column 2
Row 21, Column 3
Row 21, Column 4
Avoidance towards food or certain types of food
Row 22, Column 0
Row 22, Column 1
Row 22, Column 2
Row 22, Column 3
Row 22, Column 4
Snoring
Labored, difficult or loud breathing at night
Gasping for air while sleeping
Mouth breathes while sleeping
Mouth breathes during day
Restless sleep
Grinds teeth while sleeping
Talks in sleep
Excessive sweating while sleeping
Wakes up at night
Wets the bed (currently)
History of bed wetting
Sleepy and/or irritable during the day
Headaches
Frequent throat infections
Seasonal allergies
Ear infections or history of ear infections
Difficulty listening/ often interrupts
Hyperactive
ADD/ADHD
Sensory Issues
Speech Issues
Avoidance towards food or certain types of food
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Often
Row 0, Column 2
Always
Row 0, Column 3
Unknown
Row 0, Column 4
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Often
Row 1, Column 2
Always
Row 1, Column 3
Unknown
Row 1, Column 4
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Often
Row 2, Column 2
Always
Row 2, Column 3
Unknown
Row 2, Column 4
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Often
Row 3, Column 2
Always
Row 3, Column 3
Unknown
Row 3, Column 4
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Often
Row 4, Column 2
Always
Row 4, Column 3
Unknown
Row 4, Column 4
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Often
Row 5, Column 2
Always
Row 5, Column 3
Unknown
Row 5, Column 4
Never
Row 6, Column 0
Rarely
Row 6, Column 1
Often
Row 6, Column 2
Always
Row 6, Column 3
Unknown
Row 6, Column 4
Never
Row 7, Column 0
Rarely
Row 7, Column 1
Often
Row 7, Column 2
Always
Row 7, Column 3
Unknown
Row 7, Column 4
Never
Row 8, Column 0
Rarely
Row 8, Column 1
Often
Row 8, Column 2
Always
Row 8, Column 3
Unknown
Row 8, Column 4
Never
Row 9, Column 0
Rarely
Row 9, Column 1
Often
Row 9, Column 2
Always
Row 9, Column 3
Unknown
Row 9, Column 4
Never
Row 10, Column 0
Rarely
Row 10, Column 1
Often
Row 10, Column 2
Always
Row 10, Column 3
Unknown
Row 10, Column 4
Never
Row 11, Column 0
Rarely
Row 11, Column 1
Often
Row 11, Column 2
Always
Row 11, Column 3
Unknown
Row 11, Column 4
Never
Row 12, Column 0
Rarely
Row 12, Column 1
Often
Row 12, Column 2
Always
Row 12, Column 3
Unknown
Row 12, Column 4
Never
Row 13, Column 0
Rarely
Row 13, Column 1
Often
Row 13, Column 2
Always
Row 13, Column 3
Unknown
Row 13, Column 4
Never
Row 14, Column 0
Rarely
Row 14, Column 1
Often
Row 14, Column 2
Always
Row 14, Column 3
Unknown
Row 14, Column 4
Never
Row 15, Column 0
Rarely
Row 15, Column 1
Often
Row 15, Column 2
Always
Row 15, Column 3
Unknown
Row 15, Column 4
Never
Row 16, Column 0
Rarely
Row 16, Column 1
Often
Row 16, Column 2
Always
Row 16, Column 3
Unknown
Row 16, Column 4
Never
Row 17, Column 0
Rarely
Row 17, Column 1
Often
Row 17, Column 2
Always
Row 17, Column 3
Unknown
Row 17, Column 4
Never
Row 18, Column 0
Rarely
Row 18, Column 1
Often
Row 18, Column 2
Always
Row 18, Column 3
Unknown
Row 18, Column 4
Never
Row 19, Column 0
Rarely
Row 19, Column 1
Often
Row 19, Column 2
Always
Row 19, Column 3
Unknown
Row 19, Column 4
Never
Row 20, Column 0
Rarely
Row 20, Column 1
Often
Row 20, Column 2
Always
Row 20, Column 3
Unknown
Row 20, Column 4
Never
Row 21, Column 0
Rarely
Row 21, Column 1
Often
Row 21, Column 2
Always
Row 21, Column 3
Unknown
Row 21, Column 4
Never
Row 22, Column 0
Rarely
Row 22, Column 1
Often
Row 22, Column 2
Always
Row 22, Column 3
Unknown
Row 22, Column 4
1 of 23
14
Any history of:
Tonsils/Adenoids removal
Tooth extraction
Cavities
15
Habits:
Thumb/finger sucking
Pacifier
Bottle
Other
16
What do you ideally want for your child?
Improved overall health
Straight teeth and well-developed jaws
Potentially avoid braces
Other
17
How much do you know about Toothpillow?
Not much
I was referred by a dentist
I have basic understanding and reviewed the website
I have done a lot of research
18
Phone Number
Area Code
Phone Number
19
Is there anything specific you want explained?
The cause of crooked teeth
The risks and limitations of braces
How Toothpillow works
How treatment can potentially improve my childs overall health.
20
Who is your child's dentist?
21
What type of dentist does your child see?
Pediatric
General
They do not have a dentist
22
Is your child taking any medications?If yes, please list all medicatons.
23
When was you child's last dental exam?
WIthin the last 6 months
6-12 months ago
Longer than a year ago
They have never seen a dentist
24
Who is your regular child's dentist?
25
Questions or Concerns you'd like the Doctor to know about
26
Front Facing(click Next > to upload)
27
Front Facing Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
28
Right Side Profile(click Next > to upload)
29
Side Profile Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
30
Bite Down - All the TeethIt's important for our doctors to get a good view of your child's natural bite. So please have them pretend they're taking a bite of an apple and pause so that you can snap that photo.
31
Teeth Only Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
32
The Upper Arch
33
Upper Arch Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
34
The Lower Arch(click Next > to upload)
35
Lower Arch Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
36
Tongue to Roof Photo(click Next > to upload)
37
Tongue to Roof Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
38
My Products
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Optional: Recorded Video Evaluation from your Treating DoctorYou will receive a 5-10 min recorded video from the treating doctor reviewing your submission and discussing the specific points of concern. (Note: If you choose to move forward with a Toothpillow treatment this payment will be credited to your cost)
$50.00Edit
Back
Review by Toothpillow's Clinical Advisory BoardThis step is to determine if your child is a candidate for treatment and if virtual care is appropriate or if an in-office exam is needed.
$FreeEdit
Back
Enter Coupon
Total cost $0.00
39
Informed Consent* This field is required.
40
AAID
Should be Empty: