Date of Birth*
Preferred Method of Communication
If you can submit your photos, that will help us determine your treatment plan before your visit! When taking pictures, please use flash.
Open your mouth wide and tilt your chin down towards your chest. Hold the camera so it’s facing the biting surfaces of your lower teeth. Make sure your full arch is showing and then snap a picture.
Open your mouth wide and lift your chin as high as you can. Hold the camera so that it’s facing the biting surfaces of your upper teeth. Make sure you can see the full arch and then click.
Bite down so your back teeth touch completely. Facing the camera directly, use two fingers or spoons to pull your lips and cheeks away from your teeth. Smile wide, so you can fit as many teeth as possible in the picture and then click.
Bite down completely so that your back teeth touch. Smile and pull back the cheek with two fingers or a spoon on the right side of your mouth. Snap a picture.
Bite down completely so that your back teeth touch. Smile and pull back the cheek with two fingers or a spoon on the left side of your mouth. Snap a picture.
*maximum upload file size 4MB Each
Who Referred You?
Name of Your Dentist
Who is Your Insurance Provider?
What treatment would you like?
Limited Treatment (Braces or Clear Aligners, minor corrections only)Comprehensive Treatment (Braces or Clear Aligners, complete alignment of all teeth and bite correction)
Have you worn braces or clear aligners in the past?
Choose the option that best describes your biggest concern with your smile:
Fix a spacing issueFix a crowding issueFix a bite problem (overbite, underbite or crossbite)Generally straighter teeth
Of the images below, which one best describes your teeth crowding?
mild, or no crowdingmoderateextreme
Of the images below, which one best describes your teeth spacing?
mild, or no extra spacemoderateextreme
131 Central Avenue
Tarrytown, NY 10591
PHONE: (914) 332-0900
EMAIL: [email protected]
Monday: 9:00am – 5:00pm
Tuesday: 9:00am – 5:00pm
Wednesday: 9:00am – 5:00pm
Thursday: 9:00am – 5:00pm