Virtual Smile Assessment

For New Patients

Please answer the following questions

First Name *
Last Name *
Date of Birth *
Phone Number *
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    What type of care are you interested in?
    Orthodontics
    Pediatric Dentistry
    Do you have any concerns or are you experiencing any pain? Please describe in the box below
    If interested in orthodontics, is there a type of treatment you were hoping to undergo?
    Invisalign
    Braces
    Retainer Only
    Other
    N/A
    If interested in orthodontics, have you ever undergone orthodontic treatment in the past?
    Yes
    No
    I am currently in treatment and looking to finish it
    N/A
    Are you up to date on your dental exams and cleanings? (Have you seen your dentist for this in the past 6 months?)
    Yes
    No
    Do you have any pending dental treatment that you know needs to be completed? (This includes cavities, deep cleanings, etc)
    Yes
    No
    Unsure
    What are the most important aspect(s) of treatment for you?
    Apperance
    Cost
    Speed of treatment
    Quality of results

    Please take your smile photo just like shown below and upload it.

    Smile Photo
    Drag & Drop Files Here Browse Files
    Front Bite
    Drag & Drop Files Here Browse Files
    Left Side Bite
    Drag & Drop Files Here Browse Files
    Right Side Bite
    Drag & Drop Files Here Browse Files
    Lower Arch
    Drag & Drop Files Here Browse Files
    Upper Arch
    Drag & Drop Files Here Browse Files
    Comments

    Request an Appointment

    For orthodontic or pediatric appointment requests.

    A team member will respond as quickly as possible.

     

    First Name *
    Last Name *
    Phone *
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      Email *
      How can we help you?
      How did you hear about us? *
      Name of dentist who referred you:
      Family/friend who referred you:
      Details

      For orthodontic consultations:

      San Diego Office

      239 Laurel, Suite 201
      San Diego, CA 92101

      Phone: (619) 291-5266
      Fax: (619) 291-0124 

      Se Habla Español

      San Diego Hours

      M: 8:30 a.m. - 5:30 p.m.
      T: 8:30 a.m. - 5:00 p.m.
      W: 12:00 p.m. - 6:00 p.m.
      Th: 8:30 a.m. - 5:30 p.m.
      F: 8:30 a.m. - 1:00 p.m.

       

       

      Free Parking

      Lot is across the street, 
      East side of building on Third Ave.
      Look for Dolphin Signs