Upload Photos
If you can submit your photos, that will help us determine your treatment plan before your visit!
front view
right view
left view
upper view
lower view
Lateral Profile Image
Frontal Non Smiling
Frontal Smiling
Patient Info
First name
*
Last name
*
Phone
*
Email
*
Date of Birth
*
Name of Your Dentist
Additional Information:
Which Location Would You Like To Visit?
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Rudolphtown Office
North Clarksville Office
Who Referred You?
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Friend
Google
Yelp
Dentist
Facebook
School
Other
Are You Interested In Braces, Invisalign Or Both?
Braces
Invisalign
Both
Have You Worn Braces Or Invisible Aligners In The Past?
Yes
No
Which Picture Below Bests Describe Your Orthodontic Problem?
Crossbite
Crowding
Deep Bite
Front Teeth Protrusion
Impacted Teeth
Spacing
Open Bite
Underbite
Missing Teeth