Virtual Smile Assessment
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Step 1 / 4
First Name
*
Last Name
*
E-Mail
Phone
*
Age
I verify that I am at least 18 years old
Yes
No
Fill Required Fields
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Step 2 / 4
Do you have dental insurance?
*
Yes
No
Do you qualify for medicaid?
*
Yes
No
Have you had braces before?
*
Yes
No
Treatment Preference
*
ex. Braces, Invisalign, etc
What would you like fixed about your smile?
*
Ex. crowding, spacing, etc.
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Step 3 / 4- Upload Your Photos
Please have another person take photos of your smile for you in the various positions described below. Images must be a .jpeg, .png, or .gif and cannot exceed 20MB.
Front Smile Photo
Use spoons to pull back your cheeks and bite down on back teeth
Photo 1
Right Smile Photo
Using spoons, relax left side and pull spoon back on right side. Please show teeth from the right (bite down on back teeth)
Photo 2
Left Smile Photo
Using spoons, relax right side and pull spoon back on left side. Please show teeth from the left (bite down on back teeth)
Photo 3
Front Side Photo
*
Maximum file size: 1 MB
Right Side Photo
*
Maximum file size: 1 MB
Left Side Photo
*
Maximum file size: 1 MB
Please upload all 3 pictures
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Step 4 / 4
Additional Comments
Almost Finished!
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