Virtual Evaluation for New Patients

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Virtual Evaluation for New Patients
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Age
Today's Date

MonthDayYear
Date
Days
Responsible Party Name

First NameLast Name
Relationship to Patient

MotherFatherStep-parentGrandparentLegal guardian
Responsible Party Email
example@example.com
Email
example@example.com
Responsible Party Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Would you like a virtual evaluation?*

Yes, I want to save time and send in photos! (Photos are required to be considered for transferring treatment to our office.)No, I would prefer to schedule an in-office evaluation.
I am using an...*

iPhoneAndroid

How it Works:

1. Ask someone to help you replicate the photos below using a smartphone.

2. Submit all of your photos using the form below.

3. After Dr. Marshall reviews your photos, we will contact you.

4. Make sure you're biting down like normal; see the photo below for reference.

Top row "Fake Bite" shows the wrong bite.

Bottom row "Normal Bite" shows correct bite.

Helpful Tips
- Make sure you have good lighting.
- Clean your camera lens.
- Have someone take pictures for you, or set your smartphone on a stable surface and set the timer.
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)
Photo 1 - Right Bite

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Photo 1 - Right Bite
Photo 2 - Center

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Photo 2 - Center
Photo 3 - Left Bite

Cancelof
Photo 3 - Left Bite
Photo 4 - Upper arch

Cancelof
Photo 4 - Upper Arch
Photo 5 - Lower Arch

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Photo 5 - Lower Arch
What would you like to fix about your teeth? Please share any information that you think may be helpful.*
Dental Insurance Info (optional).

If you have dental insurance, you can upload photos of the front and back of your dental insurance card or provide the ID number and subscriber information.

This is optional and not required to submit this form.
Choose one (optional):

I'll upload photos of my dental insurance cardI'll provide the ID number & subscriber infoI have already provided this infoI have no dental insurance
Front of Dental insurance Card

Cancelof
Back of Dental insurance Card

Cancelof
Front of Dental Insurance Card
Back of Dental Insurance Card
Dental Insurance Information
Should be Empty:

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