Virtual Consultation Form

  • Virtual Consult

    At Hamilton Orthodontics, we know that your time is precious. That’s why you can see if you’re a candidate for treatment from your phone. Dr. Hamilton will assess your smile and let you know if treatment is right for you.

  • How it Works

    First, you'll start by telling us a little about yourself. Then, you'll snap a few pictures of your teeth.

  • Step 1:
    Complete the new patient history form

    Step 2:
    Take photos according to the instructions below

    Step 3:
    Upload photos to the box within the form

    Step 4:
    We will reach back out with more information and next steps!

  • Step 1:
    Complete the new patient history form

  • Date
     - -
  • Are you completing this form for yourself or on behalf of someone else?*

  • Patient Information

  • Date of Birth*
     / /
  • Has the patient reached puberty? (This can be important in treatment timing and planning)
  • Sex*
  • Preferred pronouns
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred method of communication*

  • Responsible Party Information

  • Responsible Party #1

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Would you like to add a second responsible party?*

  • Responsible Party #2

    If applicable
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Medical and Dental Information

  • Last Visit Date*
     / /
  • Please check all of the following that apply*
  • Has the patient ever had any trauma to the face, jaws, or teeth?*
  • Has the patient been informed about missing/extra teeth?*
  • Has an orthodontist been previously consulted?*
  • Has the patient had any previous orthodontic treatment?*

  • Additional Information

  • How did you hear about our office?*
  • What type of treatment are you interested in?*
  • How soon would you like to start treatment?*
  • Select payment options of interest.*
  • Do you have dental insurance?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Patient relationship to insured
  • Insured date of birth
     - -

  • Patient or Authorized Person's Signature

    To the best of my knowledge, the above information is true. I understand that it is my responsibility to inform the practice of any changes in medical status. By signing this form I also acknowledge that I have been given the opportunity to review the Notice of Privacy Practices.

  • Date
     / /

  • Photo Submission

  • Step 2:

    With your smartphone and someone to help you, replicate these 8 photos below. The better the picture you send, the more we can see and discuss!

  • Image field 5

  • Need help taking photos? Try to make sure that the room is well lit for the best quality photos.

    A good way to help retract your cheeks away from your teeth during the photos is for you to hold your cheeks with 2 spoons, while your friend or family member takes the photos for you.

     

  • Step 3:
    Upload photos below and provide any helpful information for our office. 

  • Format: (000) 000-0000.
  • Click here to take and/or upload photos
    Drag and drop files here
    Choose a file
    Cancelof

  • Step 4:
    All done! Dr. Hamilton will review your photos and get back to you soon with your treatment plan options.

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