SmilePix Order Form
Dentist Office Information
You must fill in these fields
*
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
Full face smile photos
for the Free Case only.
No Close-Ups
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 then find your patient's file
on your hard drive and upload the photo.