Virtual Smile Consult — Alexandria Orthodontics

HIPAA Compliant Encrypted & Secure Seen only by your care team

Your Information

So we know who you are and how to reach you.

First Name *

Last Name *

Email *

Mobile Phone *

Date of Birth

Zip Code

Six quick shots help the doctor see your smile. Tap each box to add a photo from your phone.

Tell us what you are looking for so we can tailor your consult.

Why are you seeking orthodontic treatment? (select all that apply)

I want to straighten my teeth I have a special occasion coming up Crowding or spacing concerns Bite or jaw issues

Describe your orthodontic goals or objectives

Which treatment method do you prefer?

How soon would you like to begin?

What matters most to you? (1 = least, 5 = most)

Quality of care

Affordability

Time & total visits

Optional. Only a couple of quick details if you have coverage.

Do you have dental insurance with an orthodontic benefit?

Yes No

Would you like us to verify your insurance benefit?

Yes No

Member First & Last Name

Insurance Provider

Member ID Number

Member's Date of Birth

HIPAA-compliant. Your information is encrypted and only seen by your care team.

Your virtual consult has been submitted. Our team at Alexandria Orthodontics will review your photos and reach out with your next steps soon.