Virtual Consultation Form
Name
*
First Name
Middle Name
Last Name
Birth Date
Please select a month
January
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Month
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Day
Please select a year
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1920
Year
Responsible Party
*
Self
Parent / Guardian
Responsible Party's Name
First Name
Middle Name
Last Name
Email
*
Confirmation Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City
*
Tell Us What You Would Like to Improve About Your Smile:
Have you worn braces or invisible aligners in the past?
Yes
No
Back
Next
Smile Profile
Please take a picture of you smiling and showing your teeth.
Photo Upload
*
Take A Photo Or Browse a Photo
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Straight Profile
Please take a picture of you with no smile
Photo Upload
*
Take A Photo Or Browse a Photo
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Side Profile
Please take a picture of you with a side profile
Photo Upload
*
Take A Photo Or Browse a Photo
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Lower Teeth
Open your mouth wide and tilt your chin downwards toward your chest. Hold the camera so it’s perpendicular to the biting surfaces of your bottom teeth. Make sure your full arch is showing and then snap a picture.
Photo Upload
*
Take A Photo Or Browse a Photo
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Upper Teeth
Open your mouth wide and lift your chin as high as you can. Hold the camera so that it’s perpendicular to the biting surfaces of your top teeth. Make sure you can see the full arch and then click.
Photo Upload
*
Take A Photo Or Browse a Photo
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Front View, Smiling
Bite down so your back teeth touch. Directly facing the camera, smile wide and click, trying to get as many teeth as you can in the picture. If you need to, you can pull your lips and cheeks away from your teeth with your fingers to show more teeth.
Photo Upload
*
Take A Photo Or Browse a Photo
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Right View
Bite down so that your back teeth touch, smile and retract the cheek and lips with your finger on the right side of your mouth to expose more of your teeth. Take a picture of the right side.
Photo Upload
*
Take A Photo Or Browse a Photo
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Left View
Bite down so that your back teeth touch, smile and retract the cheek and lips with your finger on the left side of your mouth to expose more of your teeth. Take a picture of the left side.
Photo Upload
*
Take A Photo Or Browse a Photo
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: