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Date of Birth*
Preferred Method of Communication PhoneEmail
Additional Information:
If you can submit your photos, that will help us determine your treatment plan before your visit!
#1 Front - No Smile
Look straight at the camera with no smile.
#2 Front- Smiling
Look starlight at the camera and smile as big as you can.
#3 Profile
Tuck your hair behind your ear and keep your lip relax with no smile.
#4 Lower Teeth
Open your mouth wide and tilt your chin downwards toward your chest. Hold the camera so it’s perpendicular to the biting surfaces of your bottom teeth. Make sure your full arch is showing and then snap a picture.
#5 Upper Teeth
Open your mouth wide and lift your chin as high as you can. Hold the camera so that it’s perpendicular to the biting surfaces of your top teeth. Make sure you can see the full arch and then click.
#6 Front View
Bite down so your back teeth touch. Directly facing the camera, smile wide and click, trying to get as many teeth as you can in the picture. If you need to, you can pull your lips and cheeks away from your teeth with your fingers to show more teeth.
#7 Right View
Bite down so that your back teeth touch, smile and retract the cheek and lips with your finger on the right side of your mouth to expose more of your teeth. Take a picture of the right side.
#8 Left View
Bite down so that your back teeth touch, smile and retract the cheek and lips with your finger on the left side of your mouth to expose more of your teeth. Take a picture of the left side.
*maximum upload file size 1MB Each
Who Referred You? FriendGoogleYelpDentistFacebookSchoolOther
Name of Your Dentist
Who is Your Insurance Provider?
What treatment would you like? Limited Treatment (Braces or Invisalign, minor corrections only)Comprehensive Treatment (Braces or Invisalign, complete alignment of all teeth and bite correction)
Have you worn braces or invisible aligners in the past? YesNo
Choose the option that best describes your biggest concern with your smile: Fix a spacing issueFix a crowding issueFix a bite problem (overbite, underbite or crossbite)Generally straighter teeth
Of the images below, which one best describes your teeth crowding? mild, or no crowdingmoderateextreme
Of the images below, which one best describes your teeth spacing? mild, or no extra spacemoderateextreme
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