Virtual Consultation Form FieldsetFirst Name Last Name *Age *Gender MaleFemalePhone *Email *How would you like us to respond? PhoneEmailOrthodontic Procedure you're considering When are you hoping to have this procedure done? *ASAP3 Months6 Months +Have you had any orthodontic procedures before? YesNoIf yes, please indicate procedures On a scale of 1-10, how important is this procedure to you? *What are your expectations & concerns of this procedure? *Where are you in your decision-making process? I'm just starting to think about itI've started researching procedures and doctors in my areaI've done my research, but I have more questionsI've decided I want the procedure, I'm just waiting for a good timeI'm ready to book my procedure nowOption 3PLEASE USE THE UPLOAD BUTTON BELOW TO UPLOAD PHOTOS TO SEND TO US To make the most of your virtual consultation, do your best to submit your photographs in the following format. This will allow our doctors to make the most comprehensive assessment. 1. Use a solid background. 2. Take one frontal photo with the face or body centered and looking straight. 3. Take at least one, preferably two profile photos File formats accepted: gif | png | jpg | jpeg File size limit: 3mbPhoto 1 Photo 2 Photo 3 Photo 4 By checking this box you agree to the Terms of Use listed here: *I Agree Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use. By checking this box you hereby agreeSIGNATURE *Date * VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
