hurondentalcentre - Virtual Consultation

Virtual Consultation
Thank you for considering us and giving us the opportunity to help you in transforming your smile. We will be pleased to provide an in-person or virtual consultation once you have received this quotation.

Please fill out the required submission on this form and add the images as per the given examples.

Once you submit, our Orthodontist will provide you with an estimated price for your proposed treatment within 5-7 business days.

However, you may book a complimentary in-person or virtual consultation at any time, by visiting

https://www.hurondentalcentre.com/request-an-appointment Or call us at 855 393-0900.
Patient's Name*

First NameLast Name
Parent or Guardian (If under 18)
Patient's Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*

Area CodePhone Number
Do you have any specific concerns or questions about your smile that our Orthodontist should consider?
Are you interested in Traditional Braces or Invisalign?

Traditional BracesInvisalign
Your Evaluation
Please upload your pictures following the provided images. Please make sure the bite is as natural as possible for an accurate diagnosis.
Smiling Photo*

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Frontal Smile *

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Left Bite - Please bite down on your back teeth so we can assess your bite! *

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Right Bite - Please bite down on your back teeth so we can assess your bite!*

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Top Teeth*

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Bottom Teeth*

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Upload a pan X ray (if available)

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I have been informed of the privacy policy of this office and understand that all information I have supplied will be held in strict confidence.
By submitting this information, I give consent to the team at Huron Dental Centre to evaluate my submission in order to provide an orthodontic quote and suggested treatment plan.
I understand that the quotation and suggested treatment plan are subject to change. Final pricing will be confirmed once an in person exam is completed prior to the commencement of treatment.
Parent/Guardian signature *

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Full Name*

First NameLast Name
Date*

MonthDayYear
Date
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