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Orthodontic Consultation
A few questions before your consultation so we can discuss real options.
Patient's name
*
(required)
Date of birth
*
(required)
Email address
*
(required)
Phone number
*
(required)
Who is the treatment for?
*
(required)
Select…
Myself
My child
Someone I care for
What you'd like to change
What bothers you about your teeth?
*
(required)
Which of these apply?
*
(required)
Crowding
Gaps
Overbite
Underbite
Crossbite
Protruding teeth
Teeth moved back after braces
Not sure
How long have you been thinking about this?
Select…
Recently
A year or so
Several years
Most of my life
Preferences
What would you consider wearing?
*
(required)
Clear aligners
Ceramic or clear braces
Metal braces
Lingual (behind the teeth)
Whatever works best
Aligners need wearing 20 - 22 hours a day. Is that realistic?
*
(required)
Select…
Yes
Probably
No - I'd prefer fixed braces
Not applicable
Is there a date you'd like to be finished by?
Have you looked into costs?
*
(required)
Select…
Yes, I know the range
Roughly
No idea
I'd like to discuss payment plans
History
Have you had orthodontic treatment before?
*
(required)
Select…
No
Yes, as a child
Yes, as an adult
Yes, and I stopped early
Any of these?
Grinding or clenching
Jaw clicking or pain
Missing teeth
Crowns or veneers
Gum problems
None of these
Medical conditions or medication
Leave this field empty
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