• Show Us Your Smile

    Virtual Evaluation for Existing Patients
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Patient Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • I am using an...*
  • I am a current patient checking in for virtual care for...*

  • Virtual care of current patient - other

  • My problem(s)

  • Turbo Problem

  • When did the turbo come off?
     - -
    2 digit month, 2 digit day, 4 digit year
  • From which tooth/teeth did the turbo come off?
  • When you bite down like normal, are you in an underbite (lower front teeth are in front of your upper front teeth)?
  • When you bite down like normal, do any of your teeth hit your brackets?
  • Are you in pain?

  • Powerchain, o-tie, steel-tie came off or ripped

  • When did this happen?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Can you send us clear photo(s) of the problem area?
  • Image field 107

  • Pokey wire

  • When did this start to become a problem?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Where is the pokey wire?
  • Pokey wire in the very back - where?
  • Can you send us clear photo(s) of the problem area?
  • Image field 126

  • Wire broke

  • When did this happen?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Can you send us clear photo(s) of the problem area?
  • Image field 132

  • Bracket, band, attachment, button - came off/loose

  • When did this happen?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Can you send us clear photo(s) of the problem area?
  • Image field 138

  • Turbo problem - please take a photo like below

  • iPhone User

    • Option 1 - auto-upload when taking photo (use )
    • Option 2 - take your photos first, then upload to the form (use )

  • Android User

    • Auto-upload when taking photo (use)

  • Image field 159
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  • Turbo problem - Bite down

  • Retainer/aligner - damaged or lost

  • When did this happen?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Aligner or retainer problem?
  • What's the problem?
  • What's the problem?
  • Can you send us photo(s) of the damaged retainer/aligner?

  • iPhone User

    • Option 1 - auto-upload when taking photo (use )
    • Option 2 - take your photos first, then upload to the form (use )

  • Android User

    • Auto-upload when taking photo (use)

  • Broken Turbo(s)

    Please take a biting down photo.  

  • Browse Files
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  • Photo 1

  • Take your aligners off.

  • Right Bite

  • Put your aligners on for the remaining photos.

  • Image field 37
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  • Photo 9 - Aligners on. Center. Bite Open.
  • Image field 38
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    Cancelof
  • Photo 10 - Aligners on. Left side. Bite Open.
  • Image field 40
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    Cancelof
  • Photo 11 - Aligners on. Right side. Bite Open.
  • Please specify which aligner number you are wearing and for how many days.*
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  • Photo 1 - Right Bite
  • Image field 22
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  • Photo 2 - Center
  • Image field 23
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  • Photo 3 - Left Bite
  • Image field 24
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  • Photo 4 - Upper Arch
  • Image field 25
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  • Photo 5 - Lower Arch
  • Image field 48
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  • Photo 6 - Center. Bite Open.
  • Image field 50
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  • Photo 7 - Left side. Bite Open.
  • Image field 52
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  • Photo 8 - Right side. Bite Open.

  • Submit Photos

  • iPhone User

    • Option 1 - auto-upload when taking photo (use )
    • Option 2 - take your photos first, then upload to the form (use )

  • Android User

    • Auto-upload when taking photo (use)

  • Here are some sample photos that you may want to mimick, depending on your situation.

  • Image field 184
  • Image field 175
  • Image field 196
  • Image field 193
  • Image field 187
  • Image field 190
  • Browse Files
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  • Photo 1 iphone
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  • Photo 2 iphone
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    Cancelof
  • Photo 3 iphone
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    Cancelof
  • Photo 4 iphone
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    Choose a file
    Cancelof
  • Photo 5 iphone
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    Cancelof
  • Photo 6 iphone
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