Name (First and Last): Date of Birth: JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember123456789101112131415161718192021222324252627282930311960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Address (City and Province): Email: Phone #: Preferred method of contact: PhoneEmail Click video to see how to take photos for upload Importation of photo (5mb file size max): Frontal Frontal: (Drop your photo) Frontal Smile Example Frontal Smile: (Drop your photo) Profile Example Profile: (Drop your photo) Center Biting Example Center Biting: (Drop your photo) Right Side Example Right Side: (Drop your photo) Left Side Example Left Side: (Drop your photo) Upper Teeth (occlusal) Example Upper Teeth (occlusal): (Drop your photo) Lower Teeth (occlusal) Example Lower Teeth (occlusal): (Drop your photo) What about your teeth would you like to fix? Do you visit a dentist regularly? If yes, what is their name?: When was your last dental visit?: JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember123456789101112131415161718192021222324252627282930311960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Regarding dental treatment, which is the most important to you: CostSpeedAesthetics Δ