Virtual Consultation Ortho Information
Let’s keep your treatment on track. Help us keep an eye on your smile by checking in with your doctor virtually.
Step 1
Fill out the form below.
Your Name
*
First Name
Last Name
Patient Name (if different than yours)
First Name
Last Name
Phone
-
Area Code
Phone Number
Email
*
example@example.com
Zip code
Description
*
Please provide a short summary of the issue you are experiencing.
Step 2
Upload pictures from 8 angles as illustrated in the examples below.
Profile picture (with smile)
*
Click to upload picture
Cancel
of
Profile picture (WITHOUT smile)
*
Click to upload picture
Cancel
of
Profile picture (sideways)
*
Click to upload picture
Cancel
of
Clenched teeth (left)
*
Click to upload picture
Cancel
of
Clenched teeth (front)
*
Click to upload picture
Cancel
of
Clenched teeth (right)
*
Click to upload picture
Cancel
of
Open mouth (top teeth)
*
Click to upload picture
Cancel
of
Open mouth (bottom teeth)
*
Click to upload picture
Cancel
of
Step 3: Upload Insurance Information (optional)
We'll never bill you or file a claim for this virtual consultation. It just helps us to answer questions related to how your insurance might cover future treatment. If you'd rather not provide your insurance information that's totally fine.
Please upload a FRONT picture of your insurance card.
Click to upload picture
Cancel
of
Please upload a BACK picture of your insurance card.
Click to upload picture
Cancel
of
Referral Source
We'd love to know how you learned about this service!
Referral Source
How did you hear about us?
Phone Number
-
Area Code
Phone Number
Submit
Should be Empty: