Laurel Orthodontics Virtual Consultation

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Are you a* This field is required.

New Patient

Existing Patient

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Thanks for visiting us! The first step in a new smile is to take some pictures! Take a selfie style photo of your face and smile as you look straight into the camera showing your teeth.

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Welcome Back! We miss your smiling face. To give us a little more info before your virtual appointment, please upload these images.

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Please Take A Photo of your full face

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Take Photo

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Take a photo of your smile as you look straight into the camera showing your teeth.

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Take Photo

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Take a photo of the left side of your smile.

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Take Photo

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Take a photo of the right side of your smile

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Take Photo

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Take a photo of the under side of your teeth

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Take Photo

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Take a photo of the under side of your top teeth

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Take Photo

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Name

First Name

Last Name

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Email

example@example.com

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Mobile Number

Area Code

Phone Number

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Zip Code

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Is this treatment for you or your child?* This field is required.

Me

Child

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Patient Age

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Preferred Method of Contact* This field is required.

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How long have you considered improving your smile?

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What's your main motivation for wanting to change your smile?

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Do you sometimes hide your smile?

Yes

No

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Do you have bite or jaw problems?

Yes

No

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Would you like a complimentary consultation?

Yes

No

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Is there anything else you would like to tell us about why you are seeking orthodontic treatment?

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I accept the PRIVACY POLICY, terms & conditions and acknowledge that this is only a visual guide assessment, where pictures are clear, and a visit to practice is required for a proper diagnosis.

I accept