Photo Assessment Form
Help us answer a few questions to better assist your smile!
Who is it for? (Select One)
*
My Child (7 - 11yr)
My Teenager (12 - 18yr)
Adult (18+)
I feel like my teeth are ____________.(Please choose up to two option(s) below)
*
Please check atleast one field
Overbite
Underbite
Crossbite
Crooked Teeth
Open Bite
Gap Teeth
Other
Patient's First Name
*
Patient's Last Name
*
Parent's First Name
Parent's Last Name
Date of Birth
*
Phone Number
*
Your Email Address
*
What else do we need to know?
*
Upload Your Photos
All photos should be taken sitting in a seated position. You will need a friend or family member to serve as your photographer as its difficult to try and take each of the photos below by yourself.
Images must be a .jpg, .jpeg, .png, or .gif and cannot exceed 20MB.
Photo 1
Front teeth biting down
Photo 2
Right back teeth biting down
Photo 3
Left back teeth biting down
Photo 4
Top teeth
Photo 5
Bottom teeth
Photo 6
Front teeth slightly open
Please verify.
Validation complete :)
Validation failed :(