Form

Welcome to the Haverkos & Reddy Orthodontics virtual consult platform!

In order to save you a visit for checking your retainer check 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 evaluate your retainer and ensure your smile continues to look amazing!

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 Method

Preferred Contact Time

Do you have your removable retainer? If so, do you have any concerns with your removable retainer? (ie retainer feels loose, rocks, or not fully seated)

Do you have fixed retainer(s) bonded to your teeth? If so, are they on the upper and/or lower? Do you have any concerns with your fixed retainer? (ie feels loose, poking, not bonded to a tooth, etc)

Do you have any concerns with your smile or bite? (ie rotated tooth, misalignment, uneven bite, etc)

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 not possible, it is helpful to stand up your phone and use the camera timer so you can pose and take the picture.

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 Your 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

Retainer Fit Check

Place your retainer(s) in your mouth for these pictures.

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.

Your teeth should be slightly apart.

Please take picture with retainer(s) in and teeth slightly apart

Upload or drag files here

Please Add Any Notes, Comments, or Questions

THANK YOU FOR FILLING OUT OUR VIRTUAL RETENTION CHECK FORM

We will review your retainer fit and respond within 1-2 business days.

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