First Name*
Last Name*
Email*
Phone*
Date of birth*
What Location Would You Like to Visit? ScottsdaleGuildfordLangley
Preferred Method of Communication PhoneEmail
Preferred Consultation Time 9am-12pm12pm-3pm3pm-6pm
Preferred Consultation Days MonTueWedThuFriSat
Alternative Preferred Consultation Time 9am-12pm12pm-3pm3pm-6pm
Alternative Preferred Consultation Days MonTueWedThuFriSat
Based on your above preferences, we will provide two different date/time options, and confirm with you before finalizing your appointment.
Dentist Name
Dental Office
If you can submit your photos, that will help us determine your treatment plan before your visit! Photos are optional but recommended 🙂
*maximum upload file size 4MB Each
Primary Concern CrowdingSpacingBiteJawRetainerOther
Other Concern
Have you worn braces or invisible aligners in the past? YesNo
Choose the option that best describes your biggest concern with your smile: Fix a spacing issueFix a crowding issueFix a bite problem (overbite, underbite or crossbite)Generally straighter teeth
Of the images below, which one best describes your teeth crowding? mild, or no crowdingmoderateextreme
Of the images below, which one best describes your teeth spacing? mild, or no extra spacemoderateextreme
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