We do not accept Health Partners or Keystone First. Learn More about our Membership Plans

If you are a SmileDirectClub customer, please contact our office for assistance.
If you are a SmileDirectClub customer, please contact our office for assistance.

Demographic Information

Patient Information

Name
MM slash DD slash YYYY
Parent/Guardian Name
Does the patient require antibiotics prior to dental treatment?
Call Patient

Referring Information

Referred by

Procedures

Procedures
RIGHT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
LEFT
RIGHT
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
LEFT
RIGHT
1
1
1
1
1
1
1
1
1
1
LEFT
RIGHT
1
1
1
1
1
1
1
1
1
1
LEFT
Consultations
Radiographs or Clinical Photos
Drop files here or
Max. file size: 256 MB.
    Please share any relevant pictures, radiographs or files
    This field is for validation purposes and should be left unchanged.