SS - Digital Consults

Take a Photo

First Name:

Last Name:

Email:

Patient Birthdate:

ZIP:

Phone:

I agree to the Terms and Conditions and agree to submit my photos and contact information to Red Dirt Orthodontics for review

I understand that SMS messaging may not be a fully secure form of communication, but to streamline communication with the doctor I approve of this method of contact.

Step #1

Selfie With Smile!

Step #2

Smile From Front

Step #3

Open Wide!

Step #4

Open Wide!

Step #5

Left side

Step #6

Right Side

Step #7

Insurance Card
(not required)

Step #8

Help Us Get
To Know You!

Review and Submit

Step #1

Selfie With Smile!

Step #2

Smile From Front

Step #3

Open Wide!

Step #4

Open Wide!

Step #5

Left side

Step #6

Right Side

Step #7

Insurance Card(not required)

Step #8

Help Us Get To Know You!

Review and Submit

Insurance Card
(not required)

Help Us Get
To Know You!