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 *

Your Photos *

All six shots are required. Watch the quick how-to, then add each photo below.

Start here

Watch: How to take your photos

A quick guide to getting all six shots right.

All 6 photos are required. JPG or PNG work best. iPhone HEIC photos are usually fine; if a photo shows an error, retake it or switch your camera to "Most Compatible." Max 70 MB per photo.

A Few Questions

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

Insurance

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

Review & Submit

Please confirm your details below. Tap any step on the left to make changes.

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

Thank you!