Our Philosophy
Services
Early Intervention
Pediatric Orthodontics
Airway Orthodontics
Invisalign
Modern Braces
Palate Expanders
Adult Orthodontics
Comprehensive Care
Virtual Check-Ups
Refer a Patient
Get In Touch
Book Now
Our Philosophy
Services
Early Intervention
Airway Orthodontics
Invisalign
Modern Braces
Palate Expanders
Adult Orthodontics
Comprehensive Care
Virtual Check-Ups
Refer a Patient
Get In Touch
(425) 207-0199
BOOK NOW
Orthodontic Consultation Form
Contact us any time
Patient
Age
Home Phone
Cell Phone
Date
Please Evaluate for:
Crowding
Deep Bite
Missing Teeth
Ortho/Perio
Spacing
Open Bite
Pre-Prosthetic
Rotations
Cross Bite
Class II
Class III
Interested in Invisalign/Invisalign Teen
Current Radiographs Available?
Yes
No
Radiograph Types
FMX
PANO
CBCT
OTHER
Date of Last Exam & Cleaning
Call Post Evaluation to Discuss
Yes
No
Current Care Needs Before Beginning Treatment?
Yes
No
Additional Comments, Concerns or Other Evaluation Needs:
Referring Doctor
Phone
Email
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Hours
Wednesday: 12pm-5pm
425.207.0199
13333 Bel-Red Rd. Suite 200
Bellevue, WA 98005
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