Full Name:
*
Email:
*
Phone Number:
*
Preferred contact method(s):
Email
Phone call
Text message
Other
What kind of treatment are you looking for (choose all that apply)?
Teeth Whitening
Veneers
Invisalign or Braces
Dental Implants
Smile Makeover
Would you like to add a general teeth cleaning session?
Please Select
Yes
No
Performed by highly trained staff at our facility
Interested in a comprehensive smile design consultation?
Please Select
Yes
No
We go over all available options to reinvigorate your smile based on your specific circumstances
Would you like to purchase a take-home teeth whitening kit?
Yes
No
Type of whitening:
In-office service
Take-home kit
Number of teeth for veneers:
Please Select
1
2
3
4
5
6
Full set
Material of veneers:
Please Select
Porcelain
Composite
Severity of misalignment:
Please Select
Mild
Moderate
Severe
Previous orthodontic treatment:
None
Braces
Other
Describe your current smile situation and what you would like to achieve in a smile makeover:
Can you take and upload pictures of your smile with teeth showing?
Yes
No
Please upload images of your smile with teeth:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have images of recent dental x-rays you can upload?
Yes
No
Please upload images of recent dental x-rays:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have an ideal day of week and time you'd like to come into the office?
Yes
No
For example purposes, click "Basic" for a general scheduler or click "Calendly" for an example integration of Calendly or other 3rd party scheduling platform:
General scheduler
Calendly or other 3rd party platform
When is your ideal date and time to come in for a visit?
On a scale of 1-10, how happy are you with your smile?
Do you have any additional notes or concerns?
Yes
No
Please describe any additional notes or concerns:
The total dental procedure cost would be:
Pay a deposit now:
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Cosmetic dental co-pay
Deposit for appointment scheduling and consultation
$100.00
$
100.00
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