New patient form

Name

Email

Mobile Number

Date of Birth:

Preferred Method of Communication:

Additional Information:

#1 Lower Teeth*

Open your mouth wide and tilt your chin down towards your chest. Hold the camera so it’s facing the biting surfaces of your lower teeth. Make sure your full arch is showing and then snap a picture.

#2 Upper Teeth*

Open your mouth wide and lift your chin as high as you can. Hold the camera so that it’s facing the biting surfaces of your upper teeth. Make sure you can see the full arch and then click.

#3 Front View *

Bite down so your back teeth touch completely. Facing the camera directly, use two fingers or spoons to pull your lips and cheeks away from your teeth. Smile wide, so you can fit as many teeth as possible in the picture and then click.

#4 Right View*

Open your mouth wide and tilt your chin down towards your chest. Hold the camera so it’s facing the biting surfaces of your lower teeth. Make sure your full arch is showing and then snap a picture.

#5 Left View*

Open your mouth wide and tilt your chin down towards your chest. Hold the camera so it’s facing the biting surfaces of your lower teeth. Make sure your full arch is showing and then snap a picture.

Who Referred You?

Name of Your Dentist:

Who is Your Insurance Provider?:

What treatment would you like?

Limited Treatment (Braces or Clear Aligners, minor corrections only)Comprehensive Treatment (Braces or Clear Aligners, complete alignment of all teeth and bite correction)

Have you worn braces or clear aligners in the past?

Choose the option that best describes your biggest concern with your smile:

Of the images below, which one best describes your teeth crowding?

Mild, or no crowding

Moderate

Extreme

Of the images below, which one best describes your teeth spacing?

Mild, or no spacing

Moderate

Extreme