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First Name:*

Last Name:*

Date of Birth:*

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Upload Patient Photos

Please upload photos of your bite and teeth so that we may provide you with a proper estimate.*

We require 5 separate photos to be taken and uploaded (smartphone pictures are fine) as shown in the below examples. Please name these files as follows, including your full name (no spaces) and image view (no spaces) separated by a dash or underscore:

For example, "JohnSmith-FrontBite.jpg" or "JohnSmith_UpperTeeth.jpg"

Image examples:

Please upload images here (5 images max; .jpg, .jpeg, or .png file types only):

Other information:

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