Step 1 of 3 - Your Information 33% First, please enter your full name* First Last What is your date of birth?* Date Format: MM slash DD slash YYYY What is your email address?* What is your mobile phone number?*How did you hear about us ?GoogleFacebookInstagramFrom A FriendFrom A DoctorOutdoor SignageARE 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?*YesNoWhich 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 onlyCorrect lower teeth onlyTake care of it allI'm not sure, give me all the optionsOtherPlease specify below:What is your preferred treatment method?Damon BracesClear AlignersInbrace (hidden braces)Do you prefer someone from our office to contact you for a traditional consultation?YesNo 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 FRONT SMILE*HEAD CENTRED LOOKING STRAIGHT AHEAD, THIS TIME, LET'S SEE YOUR BIG TOOTHY SMILE Drop files here or SIDE PROFILE*HEAD CENTRED LOOKING STRAIGHT AHEAD, TAKING A PROFILE PHOTO OF THE SIDE OF YOUR FACE Drop files here or RIGHT SIDE, BITING*RIGHT SIDE BITE, TEETH TOGETHER Drop files here or CENTRE BITING*FRONT BITE, TEETH TOGETHER Drop files here or LEFT SIDE BITING*LEFT SIDE BITE, TEETH TOGETHER Drop files here or LOWER BITING*BITING SURFACE OF LOWER TEETH Drop files here or UPPER BITING*BITING SURFACE OF UPPER TEETH Drop files here or If you are eligible for treatment, how soon would you like to get started?*As soon as possible, I can’t wait to Level Up my smile!Within a month or twoNot sure, it depends on the cost of treatmentHow did you hear about us?*FacebookInstagramGoogleInvisalign websiteWord of mouthOther* Before we submit your information please read our privacy policy please click the checkbox to accept. Thank You Wasn't that fun!? Click below to submit your records to Dr. Gage. Name First Last PhoneEmail
