Records Upload
Welcome! Please use this form to upload all the necessary information and records needed for me to assess your Clear Aligner Direct treatment plan.
Patient's Name
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Is your need purely cosmetic or related to issues like jaw joint pain, headaches, airway problems, snoring, or sleep apnea. Fill in as much detail here.
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What needs to change for you to feel that this treatment was worth it?
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Have you had orthodontic treatment before and, if so, the details.
Any advice or suggestions you’ve received from other professionals.
Any additional health professionals, like osteopaths or chiropractors, you’re working with so we can coordinate care.
Your general dental health
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Excellent
Not sure and will get it checked
Suspect some gum disease
Bad but getting it fixed first before Clear Aligner Direct treatment starts
Other
Have you got a dentist that can help you with the clinical aspects of treatment
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Please Select
Yes my dentist is fully on-board
Still looking for one and it wont be a problem
No, I dont have one and need help
Your city and state or province and country
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Medical History Relevant to Orthodontics (if non-contributory type "none")
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Patient’s Date of Birth
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Month
-
Day
Year
Date
Legal Age
*
Please Select
I confirm that the patient is of legal adult age
Child or dependent and I will be responsible for the treatment needs
Parent/Guardian Name (If Applicable)
Email
*
example@example.com
Phone number
Composite Photo Set (as per the instructions on the website)
*
Browse Files
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of
Smiling Extraoral Photo
*
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Repose Extraoral Photo
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Profile Smiling Extraoral Photo
*
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of
Panoramic x-ray- this is very useful
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Lateral Cephalogram- if you have one
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of
Short video from the front opening as wide as possible and closing the jaw a few times
*
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of
Postural photos (not essential)
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Save
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