914-340-1155

CSTAR Connect Membership Portal

Patient Dental Form

LET US GET YOU STARTED ON YOUR COSMETIC DENTISTRY JOURNEY!

We invite you to complete the form below to receive a detailed Quote for your particular procedure(s). Simply select your preferred destination, Dentist/Orthodontist  (if known), and we will obtain your personal feedback with a confirmed firm price.

PATIENT DENTAL FORM

The destination you are interested in getting Dental procedures from

PATIENT MEDICAL INFORMATION

FAMILY MEDICAL HISTORY

Please list all procedures

WOMEN

UPLOAD IMAGES

Photos are submitted directly to the dental professional for evaluation and feedback. We need at least one of each type listed below. You can add more if desired. Please see our Picture Submission Guidelines. Please Note: No virtual consultation can be scheduled without photos.

Panoramic X-ray
Front smile (as close as can be)
Open mouth to see bottom teeth
Open mouth to see upper teeth

VERIFICATION

Example: 12