Patient InfoHave you ever been an active patient at Rucker Orthodontics?*YesNo**** Date of Birth* Date Format: MM slash DD slash YYYY Have your teeth shifted or moved?*If your teeth have moved at all, we recommend getting a new digital impression to ensure an accurate fit of your new retainer.YesNoAre you interested in straightening your teeth?*YesNoWhat retainer(s) do you need?*Note: No tooth movement will occur. Our clear retainers will hold the current position of your teeth.Upper retainer $180Lower retainer $180Upper and Lower retainer set $360Upper and Lower retainer set + extra set $450 (Best Deal)What retainer(s) do you need?*Note: No tooth movement will occur. Our clear retainers will hold the current position of your teeth.Upper retainer $180Lower retainer $180Upper and Lower retainer set $360Upper and Lower retainer set + extra set $450 (Best Deal)Do you have the printed models of your teeth from our office?*You would have received these when you finished orthodontic treatment with us.YesNoDo you want to add custom teeth whitening?*Custom whitening trays plus 10 at-home whitening syringes.Yes ($249)NoDo you want to add custom teeth whitening?*Custom whitening trays plus 10 at-home whitening syringes.Yes ($249)NoAppointment RequiredLet's schedule an appointment for a digital impression of your teeth. Please submit this form and a member of our Smile Squad will contact you. Appointment RequiredLet's schedule an appointment for a digital impression of your teeth. Please submit this form and a member of our Smile Squad will contact you. Appointment RequiredLet's schedule an appointment with Dr. Rucker to evaluate the best option to align your teeth prior to getting retainers. Clear aligners are a great option for minor tooth movement in dialing in your smile. Please submit this form and a member of our Smile Squad will contact you. Please submit this form and bring your models to our office.. CommentsThis field is for validation purposes and should be left unchanged.
