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Patient Name *

Date of birth *

1. On a scale of 1-10, how would you rate your smile?

Selected Value: 0

2. What changes would you make to improve your smile? *

3. How would you feel if you had your ideal smile? *

4. Have you had Orthodontic (teeth straightening) treatment in the past? *

5. Would you like to have treatment to improve your smile? *

6. How soon would like you like to start treatment to improve your smile? *

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