Step One
Fill out the information below:
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Is this for your child?
Yes
No
Child's Name:
First Name
Last Name
Patient Date of Birth
-
Month
-
Day
Year
Date
Step Two
Snap photos of your face and smile!
View #1: Take a photo of your face while smiling!
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View #2: Take a photo of your face while relaxed.
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View #3: Take a photo of your profile with your face relaxed.
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View #4: Take a photo of your smile.
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View #5: Take a photo of your smile with lips retracted and teeth biting.
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View #6: Take a photo of your top teeth as shown.
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View #7: Take a photo of your bottom teeth as shown.
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View #8: Take a photo of your teeth from the left as shown.
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View #9: Take a photo of your teeth from the right as shown.
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Tell us what you would like to improve about your smile.
View #1: Take a photo of your smile.
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Step Three
Book your virtual consultation!
Preferred method of contact:
Email
Phone
Text
Enter the message as it's shown
*
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