Virtual Exam

For your convenience, we offer free virtual consultations for new patients, as well as virtual check-ins for existing patients. Please follow the instructions below to get started.

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Virtual Exam

Patient Name*

First Last

Phone*

Email*

Date of Birth*

MM slash DD slash YYYY

Are you a pediatric or orthodontic patient?*

Pediatric

Orthodontic

Are you a current patient or new patient?*

Current patient

New patient

I am in treatment with

Invisalign

Braces

Elastics

Retainers

Pediatric dentistry

Another appliance

How often are you wearing your elastics (or other appliance)?

22 Hours or more, consistently

Inconsistently

Nights only

Can not wear due to loose button or bracket

Not wearing for other reason

N/A

Are you up to date on your dental exams and cleanings? (Have you seen your dentist for this in the past 6 months?)

Yes

Do you have any pending dental treatment that you know needs to be completed? (This includes cavities, deep cleanings, etc)

Yes

Unsure

What are the most important aspect(s) of treatment for you?

Appearance

Cost

Speed of treatment

Quality of results

Do you have any concerns or are you experiencing any pain? Please describe in the box below

Smile Photo