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Personal Information To register, please take the time to fill out the information below. Title Gender Last Name First Name Birthday Birth of Place Age Home Address City Home Telephone District Office Telephone Email Mobile Occupation Referred By (Please Specify) HKID No. / Passport No. Nationality Name of Referral Emergency Contact Emergency Contact Person Relationship Emergency Contact Number Medical History Name of Physician / Specialty Most recent physical examination Purpose Your perceived general health status Excellent Good Fair Poor Do you have or have you ever had:* 1. hospitalization for illness or injury Yes No 2. an allergic reaction to aspirin ibuprofen paracetamol (acetaminophen) codeine penicillin erythromycin tetracycline local anesthetic fluoride chlorhexidine (CHX) metals (nickel, gold, silver) latex nuts fruit other 3. heart problems, or cardiac stent within the last six months 4. history of infective endocarditis 5. artificial heart valve, repaired heart defect (PFO) 6. pacemaker or implantable defibrillator 7. orthopedic implant (joint replacement) 8. rheumatic or scarlet fever 9. high or low blood pressure 10. a stroke (taking blood thinners) 11. anemia or other blood disorder 12. prolonged bleeding due to a slight cut (INR>3.5) 13. pneumonia, tuberculosis, emphysema, shortness of breath, sarcoidosis 14. chronic ear infections 15. asthma 16. breathing or sleep problems (e.g., sleep apnea, snoring, sinus) 17. kidney disease 18. jaundice 19. liver disease 20. thyroid, parathyroid disease, or calcium deficiency 21. hormone deficiency 22. high cholesterol or taking statin drugs 23. diabetes 24. stomach or duodenal ulcer 25. digestive or eating disorders (e.g., celiac disease, gastric reflux, bulimia, anorexia)25 Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 26. osteoporosis/osteopenia (i.e. taking bisphosphonates) 27. arthritis 28. autoimmune disease (e.g., rheumatoid arthritis, lupus, scleroderma) Yes No Yes No Yes No 29. head or neck injuries 30. epilepsy, convulsions (seizures) 31. neurologic disorders (ADD/ADHD, prion disease) 32. viral infections and cold sores 33. any lumps or swelling in the mouth 34. hives, skin rash, hay fever 35. STI/STD/HPV 36. hepatitis 37. HIV/AIDS 38. tumor, abnormal growth 39. radiation therapy 40. chemotherapy, immunosuppressive medication 41. emotional difficulties 42. antidepressant medication 43. alcohol/recreational drug use 44. presently being treated for any other illness 45. aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or[ diarrhea) 46. often exhausted or fatigued 47. experiencing frequent headaches 48. a smoker, smoked previously or use smokeless tobacco 49. considered a touchy/sensitive person 50. taking birth control pills 51. currently pregnant Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (e.g. Botox, Collagen Injections) List all medications taken within the last two years. Drug Drug PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING. Emergency Contact How would you rate the condition of your mouth? Excellent Good Fair Poor Previous Dentist How long have you been a patient? Date of most recent dental exam Date of most recent dental exam Date of most recent treatment (other than a cleaning) I routinely see my dentist every* 3 mo. 4 mo. 6 mo. 12 mo. Not routinely WHAT IS YOUR IMMEDIATE CONCERN? Personal History Please answer Yes or No to the following*: 1. Are you fearful of dental treatment? How fearful? 2. Have you had an unfavorable dental experience? 3. Have you ever had complications from past dental treatment? Yes No Yes No Yes No 4. Have you ever had trouble getting numb or had any reactions to local anesthetic? 5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age? 6. Have you had any teeth removed or missing teeth that never developed or lost teeth due to injury or facial trauma? Yes No Yes No Yes No Gum and Bone Please answer Yes or No to the following*: 7. Do your gums bleed or are they painful when brushing or flossing? 8. Have you ever been treated for gum disease or been told you have lost bone around your teeth? 9. Have you ever noticed an unpleasant taste or odor in your mouth? 10. Is there anyone with a history of periodontal disease in your family? 11. Have you ever experienced gum recession? 12. Have you experienced a burning or painful sensation in your mouth not related to your teeth? 13. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? Yes No No Yes No Yes No Yes No Yes No Yes No Yes No Gum and Bone Please answer Yes or No to the following*: 14. Have you had any cavities within the past 3 years? 15. Does the amout of saliva in your mouth seem too little or do you have difficulty swallowing any food? Yes No Yes No 16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? 17. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth? Yes No Yes No 18. Do you have grooves or notches on your teeth near the gum line? Yes No 19. Have you ever broken teeth, chipped teeth, or had toothache or cracked filling? 20. Do you frequently get food caught between any teeth? Yes No Yes No Gum and Bone Please answer Yes or No to the following*: 21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) 22. Do you feel like your lower jaw is being pushed back when you bite your back teeth together? 23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? 24. In the past 5 years, have your teeth changed (become shorter, thinner or worn) or has your bite changed? 25. Are your teeth becoming more crooked, crowded, or overlapped? 26. Are your teeth developing spaces or becoming more loose? 27. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together? 28. Do you place your tongue between your teeth or close your teeth against your tongue? 29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? 30. Do you clench or grind your teeth together in the daytime or make them sore? 31. Do you have any problems with sleep (i.e. restlessness or teeth grindling), wake up with a headache or an awareness of your teeth? 32. Do you wear or have you ever worn a bite appliance? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Smile Characteristics Please answer Yes or No to the following*: 33. Is there anything about the appearance of your teeth that you would like to change (shape, color, size)? 34. Have you ever whitened (bleached) your teeth? 35. Have you felt uncomfortable or self conscious about the appearance of your teeth? 36. Have you been disappointed with the appearance of previous dental work? Yes No Yes No Yes No Yes No I certify that the above information is complete and accurate.* Signature* Clear Personal Notes/Dental Notes (Official Use) Submit Registration Form

Registration Form Personal Information To register, please take the time to fill out the information below. Title Gender Last Name First Name Birthday Birth of Place Age Home Address City Home Telephone District Office Telephone Email Mobile HKID No. / Passport No. Occupation Referred By (Please Specify) Nationality Name of Referral Emergency Contact Emergency Contact Person Relationship Emergency Contact Number 醫療史 醫生姓名/以及醫生的專長 最近一次体检 目的* 你如何評估自己的整體健康狀況?* 很好 較好 一般 較差 你是否或曾經*: 因患病或受傷住院 Yes No 2. 對以下物品/程序過敏 aspirin ibuprofen paracetamol (acetaminophen) codeine penicillin erythromycin tetracycline local anesthetic fluoride chlorhexidine (CHX) metals (nickel, gold, silver) latex nuts fruit other 3. 過去六個月內出現心臟問題或安放心臟支架 4. 感染性心內膜炎病史 5. 人工心臟、修復心臟缺陷(PFO) 感染性心內膜炎病史 6. 心臟起搏器或可植入除顫器 7. 整形外科植入(關節置換術) 8. 風濕熱或猩紅熱 9. 高血壓或低血壓 10. 中風(服用血液稀釋劑) 11. 貧血症或其他血液障礙 12. 因輕微的切傷長時間流血(國際標準化比率(INR)> 3.5) 13. 肺氣腫、氣促、肉狀瘤病 14. c肺結核、麻疹、水痘 15. 哮喘 16. 呼吸或睡眠問題(即睡眠呼吸暫停、打鼾、鼻竇) 17. 腎病 18. 黃疸 19. 肝病 20. 甲狀腺、副甲狀腺或缺鈣 21. 激素缺乏症 22. 高膽固醇或在服用他汀類藥物 23. 糖尿病 24. 胃潰瘍或十二指腸潰瘍 25. 消化障礙(即乳糜瀉、胃反酸) 26. 骨質疏鬆症/骨量減少(即在服用二膦酸鹽藥) 27. 關節炎 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 28. 自體免疫性疾病(即風濕性關節炎、狼瘡、硬皮病) 是 否 29. 青光眼 30. 隱形鏡片 31. 頭部或頸部受傷 32. 癲癇、驚厥(癲癇發作) 33. 神經病學障礙 (注意力缺失症 (ADD) / 注意力缺失多動症 (ADHD)、朊病毒病) 34. 病毒性感染和唇皰疹 35. 口腔內任何腫塊或紅腫 36. 蕁麻疹、皮疹、花粉熱 37. 軟組織感染 ( STI ) /性病 ( STD ) / 人乳頭狀瘤病毒 (HPV) 38. 肝炎 39. 艾滋病病毒 ( HIV ) /艾滋病 ( AIDS ) 40. 腫瘤，異常生長 41. 放射療法 42. 化療、免抑制疫力藥物 43. 情緒問題 44. 精神病治療 45. 抗憂鬱藥 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 46. 酗酒/吸毒 47. 经常头痛 48. 吸烟者，以前吸过或使用无烟烟草 49. 被认为是一个敏感/敏感的人 50. 服用避孕药 51. 目前怀孕 是 否 是 否 是 否 是 否 是 否 是 否 請描述任何目前接受的治療、即將接受的手術、遺傳/發育遲緩或可能影響你的牙科治療的其他治療。(即肉毒桿菌、膠原蛋白注射) 請列出過去兩年內服用的所有藥物、營養補充劑和/或維他命。 藥物 目的 今後如果出現任何醫療史或服用的任何藥物變化，請通知我們。 牙病治療史 你如何評價你的口腔狀況? 很好 較好 一般 較差 你是該牙醫的病人有多長時間? 你做病人多久了? 最近一次牙科检查的日期 最近一次牙科检查的日期 最近一次治疗的日期（清洁除外） 我定期去看牙医 3 mo. 4 mo. 6 mo. 12 mo. 不经常 你最关心的是什么 個人病史 請對以下問題回答「是」或「否」*: 1. 你是否害怕接受牙科治療? 你的害怕程度有多高? 2. 你是否曾經有過不愉快的牙科治療經歷? 3. 你是否曾因以前的牙齒治療出現併發症? 4. 你是否曾經在麻醉時遇到麻煩或對局麻有任何反應? 5. 你是否曾裝過牙套、接受過牙矯正術或咬合調整? 6. 你是否曾拔牙或有從未長出的缺失牙齒? 是 否 是 否 是 否 是 否 是 否 是 否 牙齦和骨骼 請對以下問題回答「是」或「否」*: 7. 你在刷牙或用牙線時牙齦是否出血或疼痛? 8. 你是否曾接受過牙齦病治療或被告知你的牙周骨質流失? 9. 你是否曾注意到口內有難聞的味道或氣味? 10. 你的家中是否有任何人患牙周病? 11. 你是否曾出現過牙齦萎縮? 12. 你是否曾出現過牙齒自動(未受傷)變鬆或在吃蘋果時有困難? 13. 你是否曾出現過與牙齒無關的口腔內發熱或疼痛的感覺? 是 否 是 否 是 否 是 否 是 否 是 否 是 否 牙齒結構 請對以下問題回答「是」或「否」*: 14. 你在過去三年內是否曾出現過任何蛀牙? 15. 你口腔內的唾液量是否過少或在吞嚥任何食物時有困難? 16. 你是否感到或注意到你的牙齒咬合面上有任何牙洞(即點蝕、坑洞)? 17. 你是否有任何對熱、冷、咬東西、甜食敏感的牙齒或避免刷口腔內的任何部位?? 18. 你的牙齦線附近的牙齒是否有凹槽或凹痕? 19. 你是否曾出現過斷牙、碎裂牙齒、牙痛或牙隱裂補牙? 20. 你是否經常有食物卡在牙縫中? 是 否 是 否 是 否 是 否 是 否 是 否 是 否 咬合和下頜關節 請對以下問題回答「是」或「否」*: 21. 你是否有下頜關節問題?(疼痛、聲響、張開受限、鎖住、脫落) 22. 當你將牙齒咬合時，是否有下頜被往後推的感覺? 23. 你是否避免咀嚼口香糖、胡蘿蔔、堅果、百吉餅、法式長棍麵包、高蛋白營養棒或其他乾硬的食物或在吃這些食物時有困難? 24. 你的牙齒在過去五年內是否發生變化 — 變短、變薄或磨損? 25. 你的牙齒是否變得更歪斜、擁擠或重疊? 26. 你是否出現牙縫或牙齒變得更鬆? 27. 你是否需要一次以上咬、擠或移動下頜才能使牙齒對齊? 28. 你是否將舌頭放在牙齒之間或在合上牙齒時抵在舌頭上? 29. 你是否咀嚼冰塊、咬指甲、用牙齒咬住東西或有任何其他口腔習慣? 30. 你在白天是否咬緊牙齒使牙齒產生疼痛感? 31. 你是否有睡眠問題(即不安穩)、醒來時感到頭痛或牙齒不舒服? 32. 你是否佩戴或曾經佩戴咬合裝置? 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 是 否 微笑特徵 請對以下問題回答「是」或「否」*: 33. 是否有任何希望改變的牙齒外觀問題? 34. 你是否曾漂白牙齒? 35. 你是否曾對自己的牙齒外觀感到不舒服或不自在? 36. 你是否曾對以前接受的牙科診治感到失望? 是 否 是 否 是 否 是 否 I certify that the above information is complete and accurate.* Signature* Clear Personal Notes/Dental Notes (Official Use) Submit

Orthodontics Conventional Fixed Braces Remain the gold standard of treatment in orthodontics due to its efficiency, precision and 3D control. ​ There is no difference in clinical performance between metal and ceramic braces, however ceramic braces are slightly more costly. Invisalign Uses a series of clear plastic aligners to be worn 20-22 hours a day as an alternative to fixed braces. Aligners are almost invisible, generally more comfortable and have less impact on eating and brushing. But committing to wearing it is key to success. In some instances like protruding teeth or mild crowding cases aligners can perform more efficiently and effectively than fixed braces. SureSmile Aligners This is a more cost effective aligner treatment method. Suresmile is a US company that allows us to plan the tooth movements on the computer and exporting the digital files to our 3D printer to manufacture aligners in-house. This option is great for simple cases, combined treatment cases where we pair aligner treatment with fixed or lingual (behind the teeth) braces or in situations where the patient is tired or can’t wear fixed braces any more and prefers to finish in aligners. Lingual Braces We enjoy helping people with lingual braces. ​ Lingual braces are completely discreet and are better than aligners in certain situations like deep overbite cases or in extractions cases. ​ We use Suresmile lingual technology to plan the position of braces and order customised wires from the US to ensure an unparalleled level of accuracy. ​ However, lingual braces can be more uncomfortable to the tongue and generally more costly than the other options. Customized Robotic Wires Suresmile wires allow for a more efficient and precise treatment result. Because this technology provides custom archwires, we can use it for braces on the outside of the teeth or hidden braces bonded to the inside of the teeth. Our doctors are all certified, trained and maintain continuing education to be able to use this technology at the highest level.

Pediatric Dentistry Following guidelines set by International Paediatric Dental Associations, we recommend children to come in as early as 12 - 18 months of age. It is important to bring them in at an early age to allow them to familiarise themselves with a dental environment, even if it is to just have fun at their first appointment. This is to prepare a foundation for a positive attitude towards dentistry and develop healthy oral hygiene habits early on that will create a lifelong impact on their teeth. ​ We offer a wide range of services including: Toothbrushing instruction Dietary advice Prevention of dental decay Prevention of dental trauma Monitoring of skeletal growth and dental development Teeth cleaning and prophylaxis Fissure sealants Fluoride treatment Stabilisation of caries Fillings Pulp and root canal treatment Dental extraction Sports guards Labial and tongue frenectomy Sedation Sedation For dentally anxious or complex treatments for children and adults, we offer nitrous oxide (laughing gas) for light sedation to make the experience easier.

Periodontal (Gum) Treatment Periodontal Treatment Periodontal or gum disease is an infection of the gum, bone and surrounding structures of the teeth caused by the bacteria found in plaque. It is the leading cause of tooth loss in adults, and can cause halitosis (bad breath), bleeding gums, mobile teeth, and a displeasing smile for some. Gum disease is progressive and cyclical, and often painless-so you may not even be aware you have it or that it is active again. Early gum disease also known as gingivitis is characterised by swollen gums and often bleeding is reversible with improved home care and regular dental cleanings. ​ However, advanced gum disease known as periodontitis is not reversible but progression can be halted with proper maintenance. Symptoms of periodontitis may include: Gum recession Tooth mobility Bone loss Bad breath Pocketing at the gumline Attachment loss Treatment Methods Non-surgical therapy The mouth is mapped out and split into quadrants where the dentist or periodontist will focus on one side of the mouth at a time. Soft and hard deposits will be removed above and below the gum line.​ If the periodontal disease has progressed to an advanced stage, our specialist may require you to come in for a series of dental cleanings. In some cases, local anaesthetic may be administered for your comfort. Gum Grafts Some patients experience sensitivity because the roots of the teeth are exposed from loss of soft tissue either from brushing too hard, or from heavy biting surfaces causing trauma on the teeth. Some patients experience sensitivity because the roots of teeth are exposed from gum recession either from brushing too hard, or heavy bite forces. In some cases, tissue from another part of the mouth can be grafted onto the exposed area to resolve symptoms and restore aesthetics. In some cases, taking tissue from another part of the mouth can be grafted onto the exposed area can resolve symptoms.

Retail We stock dental products that we strongly believe are helpful in promoting good oral health. Some of our items are not available or hard to find in Hong Kong. ​ We have developed our own “razor floss” to make it easier for people of all ages to floss. We are also the first to provide products such as the popular US Snow home bleaching. The Plaque HD toothpaste that indicates unclean areas is also popular amongst patients. Other unique items we stock include the Curaprox tongue scraper, specialised children toothpaste or other interdental cleaning agents.

Dental Implants At Braces and Faces all implants are placed by experienced postgraduate trained dentists. Digital 3D scanners, X-rays and software are used to meticulously plan the final position before the start of treatment. ​ We use the two most reputable brands; Nobel Biocare and Straumann implants. This ensures the highest success rates and both are internationally recognised for when the crown needs to be replaced. Dental Implants Implants are often a permanent solution to missing, dead or damaged teeth. The titanium dental implant ‘root’ is anchored in the jawbone. However early tooth loss or extractions can lead to the loss of the bone that once supported the missing tooth. If insufficient bone is present to support the dental implant, additional procedures such as bone grafting and sinus lifts are required to make implants possible. There are generally 3 phases to an implant: ​ Surgical placement of implant into the jaw Osseointegration - when the bone heals around the implant which takes up to three to six months Dental Implant Crown - looks like a tooth that is attached to the implant Advantages of dental implants: Durable and hard-wearing Natural looking for a beautiful smile Strong and stable, allowing you to eat what you want Effective for oral and jaw health, holding your other teeth in position and stopping jawbone erosion Solidly implanted so there’s no slipping, giving you precise speech with no slurring or mumbling Attractive, helping your confidence and self-esteem Highly convenient A lifetime solution instead of a series of temporary ones If you are in good general health this treatment may be an option for you. In fact, your health is more of a factor than your age. You may be medically evaluated by a physician before any implant surgery is scheduled. Chronic illnesses, such as diabetes or leukemia, may interfere with healing after surgery. Patients with these issues may not be good candidates for implants. Using tobacco can also slow healing.

Oral Surgery At Braces and Faces we have specialists that perform: Extraction of erupted or impacted wisdom teeth Wisdom teeth commonly develop around 18-20 years of age. They may erupt in alignment but more often they come through at an unfavourable angle or not erupt at all. ​ Often wisdom teeth can be very difficult to keep clean resulting in cavities and gum disease affecting the wisdom teeth itself or the teeth in front. Sometimes they can also affect the position of the adjacent teeth. Removal of wisdom teeth may be difficult at times and may require a minor surgical procedure to remove them. Although not pleasant, it’s important not to compromise the long term health and position of the molars. Oral biopsies The inside of the mouth is lined with a special type of skin called mucosa which is smooth and coral pink in colour. Any alteration in this appearance (outside of genetic pigmentations) could be a warning sign of a pathological process (e.g., cancerous growth), and this could happen anywhere in the oral cavity, including the lips, gum tissue, cheek lining, tongue and the hard or soft palate. Exposure of impacted teeth Patients may have adult teeth that never erupt into the mouth due to crowding, genetic factors or unfavourable tooth positions. After the wisdom teeth, the upper canines are the most common teeth to be impacted. ​ Early detection around the age of 10 is important for the long term prongnosis of these teeth. If the teeth remain impacted then it requires “exposure”, which involves a small procedure to lift the gums away to reveal the impacted tooth for a gold chain to be bonded on and gently drawn into place by orthodontic treatment.

​ Facial Aesthetics Facial Aesthetics We are highly sensitive towards smile and facial aesthetics. We don’t believe dentistry is just about teeth. Our work can either change or are influenced by the jaw and soft facial structures (e.g, lips and cheeks). Through our orthodontic, surgical, Botox/fillers and cosmetic dental procedures (e.g. veneers) we can alter lip positions, facial lines and jaw profiles.

Joint Clicking, Pain and Grinding Joint Clicking, Pain (TMD) and Grinding Our team of dentists and specialists can diagnose the cause of the joint disorder. If suitable, our restorative dentists can provide stabilising hard or cushioning soft night guards to alleviate joint pain or reduce the harmful effects grinding has on teeth. Sleep and Grinding The dentist can support better sleep by collaborating with the sleep specialist or medical doctor by providing oral appliances for sleep apnea and snoring patients in both children and adults. ​ For children, upper jaw expansion and facial or tongue exercises may be helpful in promoting good nasal breathing, which is helpful in promoting balanced facial growth and dental development. Working with your speech therapist is often crucial for success. ​ For adults, oral appliances (e.g. SomnoMed) worn during sleep can be helpful to improve airway patency to reduce snoring or the harmful effects of sleep apnea.