New Patient Booking

Smith Smile Orthodontics

Dr. Jerry Smith

2323 Shallowford Rd. Ste 101 Marietta, GA, 30066-2000

(678) 905-0301

New Patient Information

Let's get you booked!

Already in Treatment: If you're a current patient - or transferring to our clinic to continue treatment - please call us at the number above to book an appointment.

First-timers, start here: Your free consultation awaits! Please complete the form below to get it on the books.

Patient First Name*

Patient Last Name*

Patient Date of Birth*

Are You the Patient?*

Address *

Address 2 (optional)

City*

State*

Zip*

Cell Phone*

Email Address*

One Last Question, Please...

How did you hear about us?*

I have read, understood and agree to the HIPAA Notice.

SCHEDULE