First Name*
Last Name*
Email*
Phone*
Age*
What Location Would You Like to Visit? ScottsdaleGuildfordLangley
Preferred Method of Communication PhoneEmail
Preferred Time to be Contacted 9am-12pm12pm-3pm3pm-6pm
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
What treatment would you like? Limited Treatment (Braces or Invisalign, minor corrections only)Comprehensive Treatment (Braces or Invisalign, complete alignment of all teeth and bite correction)
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
