Virtual Smile Consult

Upload a photo
Tell us what you'd like changed
We'll send you a video response

Upload a photo

Upload an existing photo from your phone or take a quick selfie.
Here are some examples:

Close Up Photo

Close Up *

Full Face Photo

Full Face (Optional)

* Please add your Close Up Photo then click next.

Tell us what you'd like changed

Information about yourself

Your Name *

Your Email *

Your Phone Number *

How did you hear about us? *

What about your smile would you like to change? *

* Please complete All Required Fields then click next.

We'll send you a video response

Please agree to terms and submit

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By clicking this box you hereby agree to hold Great Lakes Dental Care., its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties. Additionally, you understand that we will contact you as part of the function of this form.

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