Virtual Appointment

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