Existing client New client

What is it you don't like about your smile? (may select multiple boxes) *

Overlaping teeth

Gap between teeth

Gummy smile

Uneven smile

Teeth sticking out

Discolored teeth

Others

Have you had your teeth straightened in the past?

Yes No

When was the last time you used your retainer?

Years ago Months ago Still using

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

Does your job involve showing off your smile?

Yes No

Any special event have you coming in the next 12 months?

Yes No

How soon you would like to start treatment?

ASAP In a couple of weeks In a couple of monthes