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BBITE
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Is this for my child?
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First and Last Name
Patient's Name
Phone Number
Does your child snore and/or can you hear them breathe?
*
Yes
No
Email
Patient's Age
Town, City, Postcode
Does your child wake up frequently at night or get really tired during the day?
*
Yes
No
Is your child hyperactive and/or do they have difficulty focusing?
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Yes
No
Does your child grind their teeth?
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Yes
No
Does your child have nightmares?
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Yes
No
Do you want to be contacted by a Bbite Provider?
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No
Name of Current Dentist
Location of Current Dentist
Anything else you want us to know?
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