Form

Reddy & Haverkos Virtual Consult

Welcome to the Reddy & Haverkos Orthodontics virtual consult platform!

In order to provide you a virtual consultation and assess your dental concerns, please submit your information below.

Your info will be securely sent back to our team to evaluate. We hope to gather enough information to recommend a treatment plan, estimated fee, and be able to set up your first appointment to start treatment.

Enjoy and have fun starting your journey to a more confident smile!

Patient First Name

Patient Last Name

Date Of Birth

Mobile Phone

Email

Mobile Number and Email belongs to (Name of Parent, Guardian, or put self)

Preferred Contact Time

General Dental Care Provider

How did you hear about us? (Please check all that apply)

What is your chief concern with your smile and bite?

Let's Take Some Glamour Shots!

Please carefully read the instructions to help you understand what we are looking for with the pictures.

It is recommended to use your cell phone camera to take the following photos. Select the upload button and then select camera to take the recommended pictures.

Please have someone else take the photos if possible.

If you have any questions, please don't hesitate to text or call the office 481-8000.

You'll notice multiple different mouths were used for the model pictures in order to better simulate the pictures we need to assess your smile.

Smile & Profile

Take the front picture with a normal relaxed smile.

Take the side picture with lips relaxed.

Please Take The Above Photos

Upload or drag files here

Overbite & Overjet

Take the front picture pulling lips away enough to be able to see upper and lower teeth. It is helpful to use two spoons to retract the lip.

Take the side picture with a big smile and pull the lip and cheek back on one side enough to be able to see the back molars.

Remember to bite all the way down on your back teeth!

Please Take The Above Photos Biting All The Way Down On Back Teeth

Upload or drag files here

Upper Arch & Lower Arch

For the upper teeth picture, tilt the head back as far as you can and open up as wide as you can in order to see all of the teeth, even the back ones. You may need to use the spoons or your fingers to pull your lip up and out of the way.

For the lower teeth picture, tilt your head down and open as wide as you can in order to see all of the teeth, even the back ones. You may need to use the spoons or your fingers to pull your lip down and out of the way.

These pictures are tough, but they help us to see how many teeth you have in your mouth and any rotations or misalignment.

Please Take The Above Photos

Upload or drag files here

Right Bite & Left Bite

Use one finger to pull the lip back far enough to be able to see the back molars. Use your other two fingers to hold the front lips apart so the lip drape doesn't get in the way of the teeth.

Bite down as you normally would so we can see how your bite comes together.

These pictures are tough, but they help us to see your bite from the side.

Remember to bite all the way down on your back teeth!

Please Take The Above Photos Biting All The Way Down On Back Teeth

Upload or drag files here

Please Add Any Notes, Comments, or Questions

THANK YOU FOR FILLING OUT OUR VIRTUAL CONSULTATION

We will review your information and respond with questions or next steps within a business day if possible.

The treatment plan is contingent upon updating pictures and taking X-rays during your first visit.

NOTE: After submitting the form, please text the office at 513-481-8000 to confirm we received the form.