Records Upload
Welcome! Please use this form to upload all the necessary information and records needed for me to develop our patient an Invisalign treatment plan.
Dentist Rendering Treatment
*
Dentist Email (for a confirmation email post-submission)
*
example@example.com
Patient’s Name
*
First Name
Last Name
Patient's chief concern
*
Dentist's treatment goals
*
Patient Medical History Relevant to Orthodontics (if non-contributory type "none")
*
Please upload a copy of the patient's recent medical/dental history
*
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Patient’s Gender
*
Please Select
Male
Female
Non-binary
Patient’s Date of Birth
*
-
Month
-
Day
Year
Date
Patient’s Zip Code
*
Patient’s Email
*
example@example.com
Patient’s Phone Number
*
Please enter a valid phone number.
Composite Photo Set (Ortho-Photo App is helpful in creating this)
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Smiling Extraoral Photo
*
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Repose Extraoral Photo
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Profile Extraoral Photo
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Panoramic x-ray
*
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Lateral Cephalogram
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Submit
Should be Empty: