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1. How can we specifically help you?
Cosmetic Smile Design Laser Whitening Family Dentistry Periodontics X-Rays Orthodontics All of the above
Please tell us more.
2. What's most important to you in the dental care you receive?
3. Do you have a dentist currently? Yes No
4. Did you know that you can have the beautiful smile you deserve in as little as two visits? When are you planning to have cosmetic work done on your smile?
3 Months? 6 Months? Less than a year? More than a year? Do you like your smile? Yes No If you discovered an easy, safe and natural way to lighten your teeth would you be interested? Yes No Through major advances in dentistry, we can instantly straighten, upper and lower teeth, close gaps, correct chips and irregularly shaped teeth in as little as two visits. Does this interest you? Yes No
3 Months? 6 Months? Less than a year? More than a year?
Do you like your smile? Yes No
If you discovered an easy, safe and natural way to lighten your teeth would you be interested? Yes No
Through major advances in dentistry, we can instantly straighten, upper and lower teeth, close gaps, correct chips and irregularly shaped teeth in as little as two visits. Does this interest you? Yes No
5. Please tell us about yourself:
Name: Telephone: e-mail:
6. May we contact you from time to time about new advances in our practice, special offers and how best to serve your dental needs. Yes No
7. How would you like to be contacted?
e-mail: Telephone: Mailing Address: (Please enter Street, City, State, & Zip)
Please Note: E-mail is not a secure form of information and we cannot guarantee the privacy of your message.
