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Retainer Check
Patient Information
First and Last Name
*
Gender
*
Female
Male
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Cell Phone
*
-
Area Code
Phone Number
What type of retainer do you have?
Wire Retainer
Clear Retainer
How often are you wearing your retainer?
Close to 24 hours a day
Most of the time
Just at night
Sometimes
Does your retainer need adjustments?
Yes
No
Maybe
Are there any visible cracks in your retainer?
Yes
No
Maybe
Please feel free to include a picture if you would like
Browse Files
Cancel
of
If Dr Ashby feels the need to contact you, what is your preference?
*
Wait For The Pandemic (COVID19) To Be Resolved
Phone Call
Other
Which Office Is More Convenient For You?
Virginia Beach
Norfolk
Chesapeake
Any Office Works
Additional Notes:
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