Virtual Dental Consultation Form

Fill out the form below. It's an easy, free, and private way to ask about your dental concerns

Before you start filling out the form below, here’s what happens after you submit your information and photos.

Once we receive your form and photos, our expert team will review your case and respond with personalized insights, options, and next steps.

If you’d like to move forward, we’ll schedule a complete in-person exam. This enables us to confirm a diagnosis and create a personalized treatment plan tailored to your needs and goals.

Step 1

Fill out your contact information. Our expert team will be in contact with you within three business days.

Name of the person requesting a renewed smile(Required)

First

Last

Email(Required)

Enter Email

Confirm Email

Phone(Required)

Is someone helping you submit this request?(Required)

Yes

No

Are you 18+ years of age?(Required)

Yes

No

Name(Required)

First

Last

Email(Required)

Enter Email

Confirm Email

Relationship to you(Required)

Step 2

We'll need three photos of your teeth to allow us to start a path to your dream smile. Below are examples to follow. Please note:You may need someone to take it or prop up your phone & use your timer function, especially for the third photo. We accept uploads of common file formats including, including JPG, JPEG, PNG, and GIF.

Picture #1(Required)

Drop files here or

Max. file size: 9 MB.

Take a selfie of your teeth straight on, as shown. Your biggest natural smile, like it's a warm memory from your life.

Picture #2(Required)

Drop files here or

Max. file size: 9 MB.

A straight on selfie of your best, natural smile. Similar to the first photo, but this time from close up.

Picture #3(Required)

Drop files here or

Max. file size: 9 MB.

Bite down on your back teeth and pull your lips and cheeks away from your teeth with your fingers.

Step 3

Share your primary goal of a consultation.

Consent to Contact You

I consent to sharing health information electronically, I authorize communication with Glaser Dental, and I have read the policy at the bottom of the page.

Step 1 - Fill Out Contact Information

Once the form is completed our expert team will contact with you within three business days.

Name of the person requesting a renewed smile(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Is someone helping you submit this request?(Required)

Yes

No

Are you 18+ years of age?(Required)

Yes

No

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Relationship to you(Required)

Step 2 - Take Three Pictures and Upload

We'll need three photos of your teeth to allow us to start a path to your dream smile. Below are examples to follow.

Please note: You may need someone to take it or prop up your phone & use your timer function, especially for the third photo.

We accept uploads of common file formats including, including JPG, JPEG, PNG, and GIF.

Example of Picture #1 - Whole Head Selfie

Take a selfie of your teeth straight on, as shown. Your biggest natural smile, like it's a warm memory from your life.

Upload Picture #1 - Whole Head Selfie(Required)

Drop files here or

Max. file size: 9 MB.

Example of Picture #2 - Smile Close

A straight on selfie of your best, natural smile. Similar to the first photo, but this time from close up.

Upload Picture #2 - Smile Close-Up(Required)

Drop files here or

Max. file size: 9 MB.

Example of Picture #3 - Smile With Lips Retracted

Bite down on your back teeth and pull your lips and cheeks away from your teeth with your fingers.

Upload Picture #3 - Smile with Lips Retracted(Required)

Drop files here or

Max. file size: 9 MB.

Step 3 - Tell us your primary goal of the consultation

Consent to Contact You

I consent to sharing health information electronically, I authorize communication with Glaser Dental, and I have read the policy at the bottom of the page.

Disclaimer

No Doctor-Patient Relationship

Utilizing this website and/or the virtual consultation tool does not establish a doctor-patient relationship. Dr. Glaser and the Glaser Dental Team expressly disavow that a doctor-patient relationship is formed based on the use of this website and disclaim any responsibility for any decisions made by users based solely on the information provided on this platform. This virtual tool is considered the first step in evaluating your situation based on the information you provide us. With the limited information available, we provide you with potential next steps and assumptions about your case, based on our general experience. For an actionable diagnosis and a custom treatment plan, you will need a complete exam.

The team at Glaser Dental would be delighted to have you as a patient of record; however, to achieve this, you will need to undergo a comprehensive in-person exam, which includes a health history and imaging. We excel at what we do, but even with all the advances in technology, nothing takes the place of having you in the office.