Virtual Evaluation for Existing Patients

Turbo broke offPowerchain, o-tie, or steel tie - came off or rippedWire pokeyWire brokeBracket, band, button, or attachment - came off, broken or looseRetainer or aligner - damaged, broken or lostOther

Powerchain, o-tie, steel-tie came off or ripped
When did this happen?

MonthDayYear
Date
YesNo
If you're unable to send in photos, please describe the problem. (upper right, upper left, lower right, lower left?) (If the problem is associated with a tooth, please specify which tooth by counting backwards from the front tooth. Example: "upper right 3rd tooth from the front)

Pokey wire
When did this start to become a problem?

MonthDayYear
Date
In the very backSomewhere else
Upper rightUpper leftLower rightLower left
YesNo
If you're unable to send in photos, please describe the problem. (upper right, upper left, lower right, lower left?) (If the problem is associated with a tooth, please specify which tooth by counting backwards from the front tooth. Example: "upper right 3rd tooth from the front)

Wire broke
When did this happen?

MonthDayYear
Date
YesNo
If you're unable to send in photos, please describe the problem. (upper right, upper left, lower right, lower left?) (If the problem is associated with a tooth, please specify which tooth by counting backwards from the front tooth. Example: "upper right 3rd tooth from the front)

Bracket, band, attachment, button - came off/loose
When did this happen?

MonthDayYear
Date
YesNo
If you're unable to send in photos, please describe the problem. (upper right, upper left, lower right, lower left?) (If the problem is associated with a tooth, please specify which tooth by counting backwards from the front tooth. Example: "upper right 3rd tooth from the front)

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)
Turbo problem - Bite down

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Turbo problem - Bite down

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.
Photo 1

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Photo 1 iphone
Photo 2

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Photo 2 iphone
Photo 3

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Photo 3 iphone
Photo 4

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Photo 4 iphone
Photo 5

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Photo 5 iphone
Photo 6

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Photo 6 iphone
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