Submit Your First Case for No Charge

See how SmilePix cosmetic dental imaging can benefit your practice.
If you need help taking a smile portrait, go HERE.
How the SmilePix process works.

SmilePix Order Form

Dentist Office Information
You must fill in these fields* in order to submit the form.
Free Case for Dentists only.

First Name:*	Last Name:*
Company Name:
Street Address:*
City:*	State:*	Zip:*
Country (if not USA)
Telephone:*	email:*
How did you hear about SmilePix: Colleague Seminar Search on Web SmilePix email SmilePix Mailing PhotoMed Other
Colleague's name or Seminar:

Patient Information

Important In order for SmilePix to create the best quality smile simulation for you, please use a photo that looks similar to the one to the right. Full face smile photos for the Free Case only. No close-ups please! Click Here and find out how easy it is to make a good smile portrait
Patient Name*
Maxillary 6-11 7-10 5-12 4-13 All none	Mandibular 23-26 22-27 20-29 All none	Gingival Contouring Yes no
Ideal Smile yes no	Whitening yes no	Teeth Coloring A1 A2 A3 B1 B2 B3 C1 C2 C3 D1 D2 D3 none
LVI Shape Aggressive Mature Vigorous Dominant Focused Enhanced Softened Hollywood Functional Natural Youthful Oval none Click HERE to see the 12 LVI Styles	Lorin Library none F1 F2 F3 F4 F5 F6 P1 P2 P3 P4 P5 P6 R1 R2 R3 R4 R5 R6 Click HERE to see the 18 Lorin Library Styles
In the box below you can give us detailed instructions. Press Submit and than find your patient's file on your hard drive and upload the photo.