My Smile Choice™ Single Location Order Form

Please fill out the order form below to submit your practice's payment information for the My Smile Choice™ program.

My Smile Choice™ Program | Two Locations

Set-up Fee: ~~$1895~~ $1,495 + $485 (second location) one-time fee paid now

Monthly Fee: $349 + $49 (second location) auto-paid on the first of each month

+1 (888) 337-6278

Questions? Give us a call!

Step 1: Account Information

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First Name:

Last Name:

Email:

Phone:

Step 2: Billing Details

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Address:

City:

Zip:

Country:

Step 3: Payment Information

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Name On Card:

Card Number

CVC

I agree to My Smile Choice™ Beta Membership Terms & Conditions

By submitting this form, you agree to our Terms of Use and Privacy Policy.

What you'll get:

Adoption into a community of Orthodontists
Listing on MySmileChoice.com
In-office Implementation Kit
Defined Guidelines & Processes for 3 Levels of Aligner Treatment
Consultation Scripting Guide
My Smile Choice™ Consult Laminate
New Patient Contact & Intake Guide
Patient Consent Form
Customized Brochures
Customized Pass-Along Cards
My Smile Choice™ New Program Flyer
Easy to follow Marketing Plan
Micro-Site w/custom URL
Social Media Post Images & Captions
Two 45-min consultation calls
Simple Integration Worksheet & Checklist
Customized New Patient Intake Form
Consult/Case Financial Tracker

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