Step 1 of 3 - Your Information 33% PhoneThis field is for validation purposes and should be left unchanged.First, please enter your full name* First Last What is your date of birth?* MM slash DD slash YYYY What is your email address?* What is your mobile phone number?*ARE YOU A NEW PATIENT OR EXISTING PATIENT?* I am a new patient. I am an existing patient. Have you had any Orthodontic treatment in the past?* Yes No Which image(s) below best describes your current orthodontic situation?* Crossbite (Back Teeth) Crossbite (Front Teeth) Crowding Open Bite Overbite Abnormal Eruption Spacing Underbite What are you looking to improve about your smile? Correct upper teeth only Correct lower teeth only Take care of it all I'm not sure, give me all the options Other Please specify below:What is your preferred treatment method? Invisalign Traditional metal braces Clear braces Now it is time to show us your current smile. Please watch this instructional video on how to take your own virtual consultation photos. Please also use the example photos below as a reference for what your photos should look like. You will feel like a pro, promise! It is recommended to have someone take these photos for you.FRONT VIEW*HEAD CENTRED LOOKING STRAIGHT AHEAD, LIPS RESTING TOGETHER, BUT NO SMILE Drop files here or Select files Max. file size: 50 MB, Max. files: 1. FRONT SMILE*HEAD CENTRED LOOKING STRAIGHT AHEAD, THIS TIME, LET'S SEE YOUR BIG TOOTHY SMILE Drop files here or Select files Max. file size: 50 MB, Max. files: 1. SIDE PROFILE*HEAD CENTRED LOOKING STRAIGHT AHEAD, TAKING A PROFILE PHOTO OF THE SIDE OF YOUR FACE Drop files here or Select files Max. file size: 50 MB, Max. files: 1. RIGHT SIDE, BITING*RIGHT SIDE BITE, TEETH TOGETHER Drop files here or Select files Max. file size: 50 MB, Max. files: 1. CENTRE BITING*FRONT BITE, TEETH TOGETHER Drop files here or Select files Max. file size: 50 MB, Max. files: 1. LEFT SIDE BITING*LEFT SIDE BITE, TEETH TOGETHER Drop files here or Select files Max. file size: 50 MB, Max. files: 1. LOWER BITING*BITING SURFACE OF LOWER TEETH Drop files here or Select files Max. file size: 50 MB, Max. files: 1. UPPER BITING*BITING SURFACE OF UPPER TEETH Drop files here or Select files Max. file size: 50 MB, Max. files: 1. INVISALIGN PATIENTS ONLY PHOTOPlease take photo with your aligners in your mouth, of the front teeth with your teeth separated/apart) upper teeth. Drop files here or Select files Max. file size: 50 MB, Max. files: 1. If you are eligible for treatment, how soon would you like to get started?* As soon as possible, I can’t wait to fix my smile! Within a month or two Not sure, it depends on the cost of treatment How did you hear about us?* Facebook Instagram Google Invisalign website Word of mouth Other * Before we submit your information please read our privacy policy and click this checkbox to accept. Thank You Wasn't that fun!? Click below to submit your records to Dr. Dask. If you’re unable to open PDF files, you can get Adobe Reader® for free.
