Form

First Name*

Last Name*

Email*

Date of Birth*

Accepted Insurances*

Access Dental
Anthem
Avesis
Blue Cross Blue Shield
Cigna
Delta Dental
DentaQuest
Guardian
Humana
Liberty Dental
Metlife
Nevada Medicaid
Unum
PrimeCare
United Concordia
United Healthcare

State/Region*

Dental Insurance Subscriber ID*

Dental Insurance Card

Clear photo of the front and back of your insurance card

1/2

Take a quick selfie of your teeth for our dentists to examine :) No need to show us your whole face, please try to get as close as possible to your teeth.

Photo: Front facing smile*

Photo: Front and open mouth*

Photo: Left side of mouth showing teeth*

Photo: Right side of mouth showing teeth*

1/2