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 smile!
View #1: Take a photo of your face while smiling!
Browse Files
Cancel
of
View #2: Take a photo of your face while relaxed
Browse Files
Cancel
of
View #3: Take a photo of your profile while relaxed.
Browse Files
Cancel
of
View #4: Take a photo of your smile.
Browse Files
Cancel
of
View #5: Take a photo of your smile with lips retracted and teeth biting.
Browse Files
Cancel
of
View #6: Take a photo of your top teeth as shown.
Browse Files
Cancel
of
View #7: Take a photo of your bottom teeth as shown.
Browse Files
Cancel
of
View #8: Take a photo of your teeth from the left as shown.
Browse Files
Cancel
of
View #9: Take a photo of your teeth from the right as shown.
Browse Files
Cancel
of
Tell us what you would like to improve about your smile.
Step Three
Book your virtual consultation!
Preferred method of contact:
Email
Phone
Text
Enter the message as it's shown
*
Submit
Should be Empty: