Dr. Jeremy Manuele Intake

Schedule your online video consultation.

Dr. Jeremy Manuele offers convenient, fee-for-service online consultations from anywhere in the world. Send us photos and your information, and we’ll provide a personalized orthodontic analysis for maxillary skeletal expansion.

Click next to get started.

Personal Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Apartment / Suite (if applicable)

CityState

Zip CodeCountry
Email Address*
address@domain.com
Phone Number*
We'll use this to confirm your appointment.

Do you have the following information and files ready for submission?
- Clear photos of your face and inside your mouth. (Video instructions)
- Gather the CBCT scan (typically a .dcm image) or request it from your dentist or orthodontist.
Yes, I have clear photos of my face and inside my mouth, and my CBCT scan (.dcm image) is ready to upload for my online video consultation.
(Sample Video Consultations)No – I’m interested in learning more about treatment but don’t have the files ready for Dr. Manuele to evaluate at this time. I'd like more information.

	Yes
Are you anxious or nervous about dental treatment?
Do you require premedication for dental treatment?
Do any of your teeth cause you pain?
Do you have any sores or lumps in or near your mouth?
Have you had any head, neck, or jaw injuries?
Do you have ongoing jaw clicking or popping?
Do you have ongoing jaw pain?
Do you have ongoing difficulty opening or closing your jaw?
Do you have ongoing difficulty chewing?
Do you clench or grind your teeth?
Do you bite your lips or cheeks frequently?
Have you ever had speech therapy?
Is there any outstanding dental treatment to be completed?
Have you ever had instruction on the correct method of brushing and flossing?
Do bite your nails?
Do you suck your thumb?
Do you have tongue thrust while swallowing?
Do you have issues with mouth breathing?

	Yes
Hay fever / allergies
Cold sores
Migraines
Diabetes / glaucoma
Rheumatic fever
AIDS or HIV infection
Cardiac pacemaker
Asthma (inhaler)
Fainting / seizures
Thyroid problem
High / low blood pressure
Heart trouble
Epilepsy / convulsions
Acid reflux
Leukemia
Kidney / liver disease
Anemia
Cancer
Joint replacement / implants
Hepatitis / jaundice
Stomach trouble / ulcers
Sinus problems
Stroke
Radiation / chemotherapy
Respiratory problems
Bone disorder
Osteoporosis/ osteopenia
Removal of adenoids / tonsils

Face / Mouth Imaging
Please upload clear photos of your face (video instructions) and the inside of your mouth. If you need additional assistance, a video is available for your review.

Example Photos:
Add your photo files here.*

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CBCT Imaging
This DICOM (.dcm) zip/file is available from your local dentist or orthodontist. If you need additional assistance, please contact your dentist.

Helpful Guide:
- How to ZIP files on Windows & Mac
Add your DICOM ZIP here.*

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Billing Information
By submitting information and processing your payment, you acknowledge and agree that all consultations, including online video consultations and 15-minute live video consultation add-ons, are provided for informational purposes only and do not establish a doctor-patient relationship or definitive treatment plan. For full details, please refer to the service descriptions:
- Online Video Consultation Terms & Disclaimer
- 15-Minute Live Video Consultation Add-On Terms & Disclaimer
Please consult your healthcare provider before starting any treatment.

Select the consultation package(s) that works best for you.*

Pre-Recorded Video Consultation

$250.00

Add-on: Live Q&A with Dr. Manuele15-minute live session with Dr. Manuele (Pre-Recorded Video Consultation Required). Save $100 by booking now. Regular fee: $350

$250.00

Add-on: Additional CBCT Scans for ComparisonYour video consultation includes the review of one CBCT image. If you’d like us to compare multiple CBCT scans to track changes over time, select the quantity you’ve uploaded for a detailed comparison and expert analysis.

$100.00 Quantity

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

ACH Bank Transfer

Confirmation
Preferred Method of Contact for Confirmation*

EmailPhone CallText Message
I consent to Dr. Jeremy Manuele or a member of his team, collecting and using my information to contact me in order to respond to my inquiry. I understand that I can withdraw my consent at any time.*

YesNo
Best Marketing Agency*

Macbach Healthcare Solutions
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	Yes	No
Are you under medical treatment now?
Have you had any surgery?
Are you taking medication(s) including non-prescription medicine?
Do you use tobacco?
Are you aware of being allergic to any medication or substance, including metals?
Ever taken bisphosphonates for osteoporosis?

Personal Information

Dental History

Medical History

Face / Mouth Imaging

CBCT Imaging

Billing Information

Payment Methods

Confirmation