Lab Name * Name First First Last Last Phone * Email * Have you ever been an active patient at Rucker Orthodontics? * Yes No Do you have the printed models of your teeth from our office? * Yes No Have your teeth shifted or moved? * Yes No Are you interested in straightening your teeth? * Yes No What retainer(s) do you need? * Upper retainer $200 Lower retainer $200 Upper and Lower retainer set $400 Upper and Lower retainer set + Extra set $550 (Best Deal) Do you want to add custom teeth whitening? * Yes $380 No *Includes custom whitening trays plus 10 at-home whitening syringes. *APPOINTMENT REQUIRED Let's schedule an an appointment for a digital scan of your teeth. Please submit this form and a member of our team will contact you. If you are human, leave this field blank. Submit
