Smile FormPlease enable JavaScript in your browser to complete this form.Full Name *FirstLastPhone Number *Email *AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutAge *Height *What is your gender? *MaleFemaleTransgenderMarital Status *MarriedSingleDivorcedD.O.B *Weight *Number of Children *Employer *Medical Conditions, check the conditions that apply to you *NoneAsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyAnxietyWeight lossWeight gainList of Surgeries *List any previous surgeryHow often do you consume alcohol? *DailyWeeklyMonthlyOccasionallyNeverDo you use or do you have history of using recreational drugs?YesNoAre you under a doctor's care? *YesNoIf Yes, please describe. *LayoutTake and upload a picture of the front of your face smilingFront image 1 * Click or drag a file to this area to upload. LayoutTake a frontal photo with a wide smile and gaping teethFront image 2 * Click or drag a file to this area to upload. Layout (copy)Take a profile picture looking at one side of your faceSide image 1 * Click or drag a file to this area to upload. I agree to the terms & conditionsEmail/Phone/SMS message ConsentThis option seeks your approval to engage with you via email, phone calls, and mobile text messages pertaining to your Protected Health Information. Dr Iliana Suarez provides patients the ability to interact through email, phone calls, and mobile text messages. There exist several risks associated with transmitting patient information through these channels, and patients should carefully consider these before granting their consent. Dr Iliana Suarez will employ sound measures to maintain the security and confidentiality of information exchanged through email, phone calls, and mobile text messages. However, the security and confidentiality of these communication methods cannot be fully guaranteed, and Dr Iliana Suarez will not be held accountable for any unintentional disclosure of confidential information.I confirm that I have thoroughly read and understood this consent form. I am fully aware of the risks associated with these communication methods.Sing your name *Submit
