Emersonbraces - Express exam

Express exam
Follow the steps below to begin your journey to a new smile. There's a very helpful video above that will walk you through this process step by step.

Step 1: Take your Express Exam Photos as shown below.

Max size per photo is 2MB. Make sure you have cropped out any areas around your face or teeth in order to keep photos at a small enough size to upload.

Step 2: Fill out the Express Exam Form, upload your photos, and click "Submit".

Step 3: Dr. Emerson will evaluate your Smile, Teeth, and Bite.

Step 4: You will receive an email with your estimated treatment plan, treatment time and expected costs for your treatment!

We can't wait to see you smile!
Express Exam Form
Patient Name*

First NameLast Name
Date of birth

MonthDayYear
Date
Patient Age*
Please enter a number from 6 to 99
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Zip Code*
Best email for Dr. Emerson to send your Express Exam results*
What would you like to see the doctor change about about your teeth and smile?*
What are the questions you would most like answered about your teeth or smile?*
What would be your first choice of products to achieve your smile? (Information about braces and Invisalign are in the drop-down menu at the top of the page)*
(Drop down menu includes Invisalign, metal braces, clear braces)
Patient’s General Dentist
Date of Last Visit
Do you have Orthodontic Insurance?*

YESNONOT SURE
Who is your Insurance Carrier? (Cigna, Met-Life, Delta Dental, BCBS, etc.)
Insurance ID (This may be the Responsible Party’s Social Security Number)
Responsible Party’s name
Responsible Party’s Date of birth

MonthDayYear
Date
Responsible Party’s Social Security Number
Would you like us to thank anyone for referring you?
Upload Your 8 Express Exam Photos (see photo examples at the top of the page)*

Browse Files

Cancelof
Accepted file types: jpg, gif, png, pdf, jpeg

Max size per photo is 2MB. Make sure you have cropped out any areas around your face or teeth in order to keep photos at a small enough size to upload
Should be Empty:

Express exam

Express Exam Form