Photo Intake

Intake interview

With this form you can register for an intake. After reviewing the photos and your wishes, our consultants will contact you to make an appointment.

The three photos should meet the following conditions:

One picture must be taken straight ahead, one from the right and one from the left. The photos must be taken in daylight, must be sharp, and have to be zoomed in on the teeth as much as possible (no selfies!!). Make sure that the lips are raised as much as possible and that the gums are visible. For sample photos, please take a look at the before and after photo section of this website.

Please also state your complaints and wishes regarding your teeth on the digital intake form. Would you like to keep your teeth as natural as possible or would you prefer a ‘Hollywood smile’? Would you like a change in position and/or shape?

In some cases, the photo intake can replace the personal intake; however, it is usually advisable to make an appointment for a personal intake as well, and the photo intake serves as a rough estimate of the possibilities and costs. We offer the photo intake free of charge.

Intake form

All fields are required!

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At which location would you like to be treated?

No Preference
Prinsenbeek
Baarn

What is your name?

First

Last

Gender

Male
Female

Lay-out

E-mail

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Date of Birth

BSN-number

When did last you visit the dentist?

Do you speak English or Dutch?

Do you already have any crowns, veneers and/or bridges?

Upload 3 photos of your denture

Photo 1

Click or drag a file to this area to upload.

Photo 2

Click or drag a file to this area to upload.

Photo 3

Click or drag a file to this area to upload.

What would you like to achieve, when it comes to your denture?

Photo Intake

Intake interview

Intake form

Restyle your Smile

Prinsenbeek

Baarn

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