Patient Name *

Phone *

Email *

What's your main concern that you'd like our doctors to address? *

Do you have dental/orthodontic insurance? We accept all insurance providers *

Do you have dental anxiety, sensitivities, or anything else you’d like us to consider during your visit? *

When are you hoping to start treatment? *

By checking this box, I consent to receive non-marketing text messages from Happy Smiles Orthodontics about my appointments. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new treatment plans among others from Happy Smiles Orthodontics at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.