Photo Intake

Intake interview

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

The three photos must meet a number of conditions:

One picture must be taken straight ahead, one from the right and one from the left. The photos must be taken in daylight, sharp, and zoom in on the mouth 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 our before and after photos.

Please also state your complaints and wishes regarding your teeth on the digital intake form. Do you want to keep your teeth as natural as possible or do you want 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!

      In which branch of Restyle Your Smile would you like to be treated?

    First name

    Last name

    Address

    Housenumber

    Postal code

    City

    Date of birth

    Phone number

    E-mail

    When was your last dental visit?

    Do you already have facings, crowns or bridges?

    Upload three pictures of your teeth

    Photo 1:

    Photo 2:

    Photo 3:

    What are your wishes regarding your teeth?

    Input this code: captcha