Dexter Orthodontics

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Please submit your costume and contact information for a chance to win our Squishmallow and Lego Star Wars raffle! Deadline to enter is October 31.

Child First Name*

Child Last Name*

Age*

Legal Guardian Name (if under 18)

Are you a patient of Dexter Orthodontics?

Email*

Phone Number*

Enter me in*

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Additional Comments

By checking this box I certify that I am 18 years of age or older (or have permission from my legal guardian.)

Please send me information on a complimentary orthodontic exam for my age 7+ child. (No referral required!)

If you are having trouble with the online form, email your responses to info@dexterortho.com.