Your Name
Full Name
*
Phone
Phone
*
Email
Email
*
What are your main concerns with your teeth?
What concerns you most about your teeth and smile?
*
Do you have a preferred treatment method?
Preferred Treatment Method
*
Select
Braces
Invisalign/Clear Aligners
Either Treatment Is Fine
Unsure
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Now we need to capture some photos of your smile. You will need to take 5 photos of your teeth so that Dr Gullotta can assess your smile and bite.
Image 1 Example: Centre
Intraoral Front
Intraoral Front
Image 2 Example: Left Side
Intraoral Left
Intraoral Left
Image 3 Example: Right Side
Intraoral Right
Intraoral Right
Image 4 Example: Upper Teeth
Maxillary Occlusal
Maxillary Occlusal
Image 5 Example: Lower Teeth
Mandibular Occlusal
Mandibular Occlusal
Please upload any additional information or documents you may have, such as a dentist referral.
Additional Records
Additional Records
Submit Photos