Virtual Appointment

    Name (First and Last):

    Date of Birth:

    Address (City and Province):


    Phone #:

    Preferred method of contact:

    Click video to see how to take photos for upload

    Importation of photo (5mb file size max):

    Frontal Smile

    Frontal: (Drop your photo)

    Frontal Smile Example
    Frontal Smile

    Frontal Smile: (Drop your photo)

    Profile Example

    Profile: (Drop your photo)

    Center Biting Example
    Center Biting

    Center Biting: (Drop your photo)

    Right Side Example
    Right Side

    Right Side: (Drop your photo)

    Left Side Example
    Left Side

    Left Side: (Drop your photo)

    Upper Teeth (occlusal) Example
    Upper Teeth (occlusal)

    Upper Teeth (occlusal): (Drop your photo)

    Lower Teeth (occlusal) Example
    Lower Teeth (occlusal)

    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?:

    Regarding dental treatment, which is the most important to you: