What is your main motivation to improve your smile?
*
GENERAL SELF-IMPROVEMENT
EXCEL IN MY CAREER
I HAVE AN UPCOMING EVENT
OTHER
Have you previously worn braces or Clear aligners?
*
No
Yes
Describe Your teeth crowding?
*
MILD
MODERATE
SEVERE
NONE
How’s your teeth spacing?
*
MILD
MODERATE
SEVERE
NONE
How’s your bite?
*
CROSSBITE
UNDERBITE
OVERBITE
NONE
Have you lost all your baby teeth?
*
NO
YES
Do you have any existing dental work?
*
NO
I HAVE SOME BRIDGE WORK
I HAVE SOME MISSING TEETH
OTHER
What is most important to you in Orthodontic Treatment?
*
FAST RESULTS
EASE OF USE
LOW PRICE
DISCREET & PRIVATE
What kind of insurance do you have?
*
DENTAL INSURANCE
FSA/HSA/HRA ACCOUNT
NO INSURANCE
NAME
*
EMAIL
*
PHONE
*
WOULD YOU LIKE TO REQUEST A FREE CONSULT?
*
YES
NO
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