Back
Find The Path To A Better You.
In order for our doctors to prepare for a one-on-one consultation and assess your smile, face and/or neck, or sleep concerns, please submit your information below.
Your information will be securely sent back to our team to evaluate.
Which of the following are problem areas for you? (Check all that apply)
Do you have a big life event coming up? (Wedding, graduation, anniversary trip, career event, other)
When is your event?
Smile/Teeth Questionnaire
Please complete the following questions related to your smile and teeth.
If there are no questions shown, please click "Next" to proceed.
How would you rate your smile?
When I see a picture of myself, the first thing I notice about my smile is:
Would you prefer to have brighter teeth?
Are you missing any teeth?
While smiling, are you happy with how much your teeth show?
In terms of the length of your teeth, do you feel that your teeth are?
Would you like to change the angle or orientation (slanted or rotated) of any of your teeth?
Do you have any staining you'd like to have removed?
How do you feel about the amount of gums that shows when you smile?
Do you think the gum tissue around your teeth is symmetrical?
Are you happy with the width of your smile?
Do you have any dark crown margins that are visible or inflamed gums around a crown or filling?
Are you concerned about wear or chipping on your front teeth?
Are you self-conscious about visible dark metal fillings when you smile?
If you could make any other changes to the look of your smile, what changes would you make?
Face/Neck Questionnaire
Please complete the following questions related to your face and neck.
If there are no questions shown, please click "Next" to proceed.
Are you happy with your overall skin appearance around your face and neck?
Is the skin on your face or neck dull or rough?
Do you have fine lines or wrinkles on your face?
Do you have "crows feet" or fine lines around your eyes?
Do you have creases or lines around your mouth?
Does your lipstick "bleed" into these lines?
Do you have large pores or uneven skin texture on your face?
Do you have acne?
Do you have acne scars?
Do you have melasma or pigmented skin?
Do you have rosacea or skin redness?
Do you have unwanted facial hair?
Do you have aging skin around your chin?
Do you have jowels or loose skin around your lower face?
Do you have crepey or sagging skin on your neck?
Do you have sunspots on your face or neck?
Do you have sun damage on your neck or decollete' (upper chest area)?
Do you have loose skin or fullness under your chin area?
Do you have any other facial or neck area skin concerns?
Sleep Questionnaire
Please complete the following questions related to your sleep.
If there are no questions shown, please click "Next" to proceed.
Do you experience daytime sleepiness?
Do you experience insomnia?
Do you snore loudly?
Do you wake from sleep with a choking sound or gasping for breath?
Do you feel unrefreshed when you wake up?
Is there anything else you would like to share about your sleep issues?
Selfie & Profile
Please Take The Above Photos
Selfie and Profile Photos Uploader
Upload
or drag files here
Please Take The Above Photos If You Selected
SMILE/TEETH
As Your Concern
Overbite and Overjet Images Uploader
Upload
or drag files here
Please Take The Above Photos
If You Selected
SMILE/TEETH
As Your Concern
Upper Arch and Lower Arch Images Uploader
Upload
or drag files here
Please Take The Above Photos
If You Selected
SMILE/TEETH
As Your Concern
Right and Left Bite Images Uploader
Upload
or drag files here
Your Contact Information
First Name
Last Name
Date Of Birth
Sex
Preferred Contact Method
Preferred Contact Time (check all that apply)
Phone
Email
Comments
Back
Next
Back
Next
Submit
Done