Patient Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Best way to contact you?
Please Select
Call
Text
Email
Preferred location?
Please Select
Westlake
Downtown
Domain
First available
Do you have orthodontic benefits?
Please Select
Yes
No
I am not sure but let's chat on the phone call.
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Next
Policy Holder's Dental Insurance Information (Full name as it reads on your card)
*
*Policy Holder's First Name:
*Policy Holder's Last Name:
Policy Holder's Birthdate:
*
 -
Month
 -
Day
Year
Relationship to Patient:
*
Policy Holder's Relationship to Patient
Would you like to upload images of your insurance card?
Please Select
Yes, upload my insurance card
No, fill out insurer manually
We verify your benefits before your appointment so we can give you the treatment cost same day with your estimated insurance included.
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Next
Insurance Company:
*
Subscriber ID # or SSN:
Insurance Company Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Phone Number:
Please enter a valid phone number.
Do you have dual dental coverage?
Please Select
Yes
No
If you are covered under two different dental insurance plans, then you have dual dental coverage.
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Next
Upload FRONT & BACK image of your insurance card.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Next
Tell us a little more about what brings you to us?
Please Select
Seeking orthodontics for myself
Seeking orthodontics for a family member
Dentist referral
2nd opinion
What is the main motivator?
Please Select
Bite
Esthetics
Other
How did you hear about us?
Please Select
Google
Instagram
Facebook
Influencer
Dentist
Word of Mouth
Friend/Family
Other
Is there anything else you would like us to know?
Submit
Should be Empty: