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Dr. Chelian Orthodontics
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Online Smile Assessment Step 1:

Fill In Contact Information

Online Smile Assessment Step 2:

Do You Have Insurance?

Do You Qualify For Medicaid?

If you provide your insurance information and complete and submit the forms listed below, we can inform you of any additional benefits or discounts you qualify for that may reduce your out of pocket expense (the forms are not required for the assessment, but may help provide you with a firmer cost estimate).

Click on the links below to download the forms.
Patient Information Form
Insurance Verification Form

Files must be a .pdf and must be less than 5MB.

Patient Information Form

 

Insurance Verification Form

 

Online Smile Assessment Step 3:

Upload Your Photos

All photos should be taken sitting in a seated position. You will need a friend or family member to serve as your photographer as it’s difficult to try and take each of the photos below by yourself.

Images must be a .jpg, .jpeg, .png, or .gif and cannot exceed 20MB.

Photo 1

Frontal Smiling:

Bite down and give a really big smile. Make sure your back teeth are touching.

Photo 1 - Frontal Smiling

Photo 2

Frontal Gums:

Smile very big again, but this time keep your teeth slightly apart and pull back your lips with your fingers so your top and bottom gums are visible.

Photo 2 - Frontal Gums

Photo 3

Profile:

Smile really big (one more time!) and bite down on the back teeth - the way you would if you were chewing something. In this photo we need to be able to see both the bottom and top teeth.

Photo 3 - Profile

Online Smile Assessment Step 4:

Additional Comments

Please review this form using the BACK button below (DO NOT use the browser back button).

If you are finished, click the SUBMIT button to send your assessment to the doctor.

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Request A Free Exam

Nashua 603-882-6100
29 Riverside Street Nashua, NH 03062
Danvers 978-774-8266
36 Conant Street, #3 Danvers, MA 01923