New Face MD Form

Do you suffer from any of the following health conditions such as (please select all that apply) / Padeces alguna de las siguientes condiciones de salud, tales como (selecciona todas las que correspondan) *

Do you smoke any of the following? / Fumas alguna de estas opciones *

Tobacco

Marijuana or THC

Vape

Are you pregnant? / ¿Estás embarazada?

Existing dental work

Do you have Resin veneers? / ¿Tienes carillas de resina? *

How many? / ¿Cuántas?

Do you have Porcelain veneers? / ¿Tienes carillas de porcelana?

How many? / ¿Cuántas?

Do you have Implants? / ¿Tienes implantes? *

How many? / ¿Cuántos?

Do you have Crowns? / ¿Tienes coronas? *

How many? / ¿Cuántas?

Do you have Bridges? / ¿Tienes puentes? *

How many? / ¿Cuántos?

Do you have temporaries? / ¿Tienes temporales? *

How many? / ¿Cuántos?

Do you have Removable prosthesis? / ¿Tienes prótesis removibles? *

If you have an Implant do you have the crown in place? / Si tienes un tipo de implante, ¿tienes la corona en su lugar? *

Brand of implant that was used / Marca del implante

If you dont have the brand please try to obtain the records and information from the dental office that placed the implant in order for us to help you / Si no tienes la marca, por favor intenta obtener los registros e información del consultorio dental que colocó el implante para que podamos ayudarte.

Evaluation

Front face 1 *

Take a picture of the front of your face, with a full smile

Choose file

Front face 2 *

Take a picture of the front of your face, using your two fingers.

Choose file

Front face 3 *

Take a picture of the front of your face (Opening the teeth a little bit), with the help of your fingers

Choose file

Right side *

Take a picture of the right side of your face, with a full smile

Choose file

Left side *

Take a picture of the left side of your face, with a full smile.

Choose file

Dental insurance

Please attach a photo front and back of your dental insurance / Adjunta una foto del frente y la parte posterior de tu seguro dental

Front

Take a picture of the front of your dental insurance / Toma una foto del frente de tu seguro dental.

Choose file

Back

Take a picture of the back of your dental insurance / Toma una foto del reverso de tu seguro dental.

Choose file

**By checking this box and clicking submit below, I expressly authorize New Face MD to deliver to my phone number and/or email address, communications using an automatic telephone dialing system, an artificial and/or a pre-recorded voice by phone calls, text messages, voicemails, and emails advertising its services, products, promotions, appointment, account information. I can unsubscribe or provide notice to New Face MD that I would like to opt-out at anytime. I understand I’m not required to opt in to purchase goods or services.

Once you have filled in the form, please click on submit and wait for the system to upload the information / Una vez que hayas llenado el formulario, por favor haz clic en 'Enviar' y espera a que el sistema cargue la información

Please, confirm Email / Por favor confirma tu correo electrónico

Emails do not match.

Dental Online Evaluation

Procedure information

Health Status

Existing dental work

Evaluation

Front face 1 *

Front face 2 *

Front face 3 *

Right side *

Left side *

Dental insurance

Front

Back