How do you want to obtain your best smile? (Select all that apply)
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Metal Braces
Clear Braces
Invisalign (clear aligners)
Whitening
Replacement Retainer(s)
Have you visited our office before?
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Patient Information
Patient Full Name
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Patient Date of Birth
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Responsible Party
Responsible Party Full Name
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Responsible Party Date of Birth
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Phone
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Email
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Dental Insurance
Do you want us to verify your dental insurance benefits?
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Please message us any additional information you would like us to know.
If you are in active orthodontic treatment, please check this box (currently have braces).
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