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Orthodontic Questionnaire
In order to provide you a virtual consultation and assess your dental concerns, please submit your information below.
Your information will be securely sent back to our team to evaluate.
1. What best describes your primary orthodontic concern?
2. Do you have difficulty or pain, or both, when chewing, talking, or using your jaw?
3. What treatment options are you interested in?
4. If you could make any changes to the look of your smile, what changes would you make?
Smile & Profile
Please Take The Above Photos
File Uploader
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Overbite & Overjet
Please Take The Above Photos
Left: Bite all the way down on your back teeth. Do not push your lower jaw forward.
Right: Bite all the way down on your back teeth. Take a side view showing top/bottom front teeth.
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or drag files here
Upper Arch & Lower Arch
Please Take The Above Photos
Left: Open as wide as possible to get the underside of your upper teeth.
Right: Aim over the top of your lower teeth. Pull your lower lip down.
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or drag files here
Right Bite & Left Bite
Please Take The Above Photos
Bite all the way down on your back teeth. Take right and left view of your back teeth.
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or drag files here
First Name
Last Name
Date Of Birth
Phone
Email
Preferred Contact Method
Preferred Contact Time
Notes, Comments, or Questions
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