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: