Fully HIPAA compliant. Secure. We won’t share. Step 1 of 4 25% Contact Information Patient's First Name Patient's Last Name Parent or Guardian (if under 18) Patient's Date of Birth MM slash DD slash YYYY Email Address Phone NumberZip Code Insurance Name Policy Number Medical InformationDo you have any allergies, medical concerns or currently taking any medication? Please list below.My Smile AssessmentWhy would you like to straighten your teeth? What is your biggest concern with your smile? Have you worn braces or clear aligners in the past? Treatments I'm interested in: Traditional Braces Invisalign Uncertain Preferred LocationSelect OfficeFort Walton Beach OfficeNiceville Office Please watch this video for instructions on how to take good pictures. After you are done watching the video, go to the next page to take pictures and upload them. Please upload your pictures here for your Smile Assessment Frontal Photo Facial FrontalAccepted file types: jpg, png, jpeg, Max. file size: 5 MB.Smiling Photo Facial Frontal SmilingAccepted file types: jpg, png, jpeg, Max. file size: 5 MB.Profile View Facial LateralAccepted file types: jpg, png, jpeg, Max. file size: 5 MB.Front Buccal center with teeth biting on the back teethAccepted file types: jpg, png, jpeg, Max. file size: 5 MB.Right Buccal right with teeth biting on the back teethAccepted file types: jpg, png, jpeg, Max. file size: 5 MB.Left Buccal left with teeth biting on the back teethAccepted file types: jpg, png, jpeg, Max. file size: 5 MB.Top Occlusal UpperAccepted file types: jpg, png, jpeg, Max. file size: 5 MB.Bottom Occlusal LowerAccepted file types: jpg, png, jpeg, Max. file size: 5 MB. Authorization I understand that the information that I have given today will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status. By submitting this information, I consent to The Happy Tooth Orthodontics and their team of Orthodontists evaluating my submission in order to provide an orthodontic quote and suggested treatment plan. I understand that the quote and suggested treatment plan I receive from my virtual consultation are subject to change, if and when an in-person exam is completed.Signature* HiddenLocation CAPTCHA