Virtual Consultation

Let’s create a beautiful smile together!

Welcome to your virtual consultation! Taking a moment to fill out our virtual consultation form will help us create the beautiful smile you deserve! Please answer the questions below to the best of your ability. Dr. Hardy will review your form and send you your consultation within 2 business days. This consultation will include treatment and financial options.

As you go through this form if you need help feel free to call our office. We are here to help and if you prefer can always schedule a video teleconference with the office as well.

First, tell us about your smile!

"*" indicates required fields

Step 1 of 2

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Please tell us, in your own words, why you are seeking orthodontic treatment*

What is the date of birth of the patient we will be evaluating?*

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Now, we need some contact information:

Name*

Email*

Phone*

Optional: Is there any insurance you would like us to check for you? If so, please fill out the form below. This information may allow us to more accurately provide you with financial options!

Primary Insurance Holder Name

Employer:

Insurance Company:

ID #:

Insurance Phone:

You're almost done. Now, we just need some pictures!

For this part of your virtual consultation, you will need a camera (your smartphone will work just fine), and a family member or friend! We know this part of the consultation can feel awkward or embarrassing, but these pictures allow us to provide you with the most accurate information. We promise there is no judgment here! We have also included a video to explain the best way to take the pictures.

Front-Facing Straight Face:

Accepted file types: jpg, gif, png, pdf), Max. file size: 100 MB.

Front-Facing With Smile:

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

Profile:

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

Front Teeth Close Up

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

Side Teeth Left

Max. file size: 100 MB.

jpg, gif, png, pdf

Side Teeth Right

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

Upper Mouth

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

Lower Mouth

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

Treatment recommendations and financials are just estimates based on the photos that you send us. Your photos cannot be considered diagnostic and the treatment recommendations do not indicate any finalized findings or recommendations. Until an in-person exam is done with the doctor, anything diagnostic cannot be given concerning your oral health. With that, do know the financials are estimates as well.

By submitting this form you are agreeing that you are submitting and receiving certain information via non-secure emails.*

I agree