Envision A Smile - Submit Your Case

Submit Your Case

Please complete the form below to submit your case
Practice Name: *
Email: *
example@example.com
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Imaging Information
Patient Name: *

First Name Last Name
Note: Please ensure all file names do not include any special characters to include periods, hyphens, or underscores and the file sizes are smaller than 5MB prior to uploading them to this site.
Upload Image (Frontal):

Cancel of
Upload Image (Lateral):

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Upload Image (Full Face):

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Treatment Plan: Please specify teeth numbers to image here and any other information you would like to add (Style, Embrasures, Etc.) *
Shade Desired: *
Do you desire balance of gingival tissue? *
By checking this box I agree that to my knowledge the above information is accurate *

I agree
Please verify that you are human *
Should be Empty:

Submit Your Case