SmilePix Free Order Form

Dentist Office Information


You must fill in these fields* Free Case for Dentists only.
First Name:*
Last Name:*
Company Name:
Street Address:*
City:*
State:*
Zip:*
Country (if not USA)
Telephone:*
email:*
How did you hear about SmilePix:
Colleague's name or Seminar:

Patient Information


Full face smile photos
for the Free Case only.

No Close-Ups
Click Here and find out
how easy it is to
make a good smile portrait
Patient Name*
Maxillary
Mandibular
Gingival Contouring
Ideal Smile
Whitening
Teeth Coloring
LVI Shape

Click HERE to see the
12 LVI Styles
Lorin Library

Click HERE to see the
18 Lorin Library Styles

In the box below you can give us detailed instructions.

Press Submit and then find your patient's file
on your hard drive and upload the photo.