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(check all that apply)
1. I am concerned about:
The appearance of my teeth or my smile
The whiteness of one or more of my teeth
The position or angle of of one or more of my teeth
The shape of one or more of my teeth
2. In social situations, I am sometimes embarrassed by my teeth or my smile:
Yes
3. There are some things I would like to change about my:
Upper front teeth
Lower front teeth
4. I have old fillings or previous dental treatment that is no longer satisfactory to me:
Yes
5. I am missing one or more of my teeth:
Yes
6. I am interested about learning more about esthetic (cosmetic) dentistry:
Yes
7. I would like to:
Schedule a visit
Receive a follow-up contact from Sensitive Care
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