Smile Makeover Consultation Form

Smile Makeover Consultation

Complete the form below, then click the link provided to immediately schedule your FREE 15-minute virtual call with Dr. Daniel.
Name*

First NameLast Name
Not happy with?*

Size of the teethShape of the teethColor of the teethTeeth crowding/spacingAlignment of teeth (overbite, underbite, etc)None
When are you hoping to get started or have your smile complete?*
Do you have a budget range you’d like us to stay within?*

$5,000 - $10,000$10,000 - $20,000No Specific Budget
If your current goals include whitening, straightening, or restoring a few front teeth, a budget of $5K–$10K may be appropriate for a partial transformation.
For a complete smile transformation (typically 8–10 upper teeth), a realistic investment starts above $10,000. If you’re seeking a full smile makeover, we recommend selecting the $10K–$20K or “No Budget” option so we can properly plan your ideal result.
We’re here to guide you toward the best option — both visually and financially — so your smile aligns beautifully with your vision.
Lastly, do you have a preferred payment method or plan (e.g., savings, credit, financing, HSA/FSA, etc.) so we can align with your comfort?*
Do you have any of these procedure?*

Crowns/VeneersBridges/ImplantsMissing Tooth/TeethRoot CanalsNoneOther
Gender?*
Provide details about ways you would like to improve your smile. Include what you like vs. dislike, your desired smile, and/or barriers (time, money, etc). Be as detailed as possible. Also, feel free to ask us any concerns you have. *
Are you looking to improve your entire smile, or are there specific teeth or areas you’re most concerned about? If so, which ones?
Upload the Following Pictures for Our Assessment:

Please ensure that all photos are clear and captured at the angles requested. All photographs are protected and confidential.
Photo 1: Take a photo of your natural smile as shown in the photo above. *

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Photo 2: Use your fingers to retract your lips and ensure there is adequate lighting before taking your photo. *

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Photo 3: Use your fingers to retract your lips and ensure there is adequate lighting before taking your photo. *

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Photo 4 (Upper Teeth): Use your fingers to retract your lips and ensure there is adequate lighting before taking your photo. *

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Photo 5 (Lower Teeth): Use your fingers to retract your lips and ensure there is adequate lighting before taking your photo. *

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Email*
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How Did You Hear About Us?*
Phone Number*
Please enter a valid phone number.
Thank you for completing our consulation form. Pricing and scheduling details will be delivered via email once our team has had time to review your case. We look forward to working with you!
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