Am I a candidate for professional whitening?

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number

Area Code

Phone Number

4

Birthdate

Date

5

Approximately how long since your last check up with a dentist?

6

Approximately how long since your last dental cleaning?

8

Have you used any professional or over the counter whitening products in the past? Examples: professional in office whitening, custom whitening trays+gel, another Wicked White product, whitening at a spa, Crest White Strips, whitening toothpaste....

9

To the best of your knowledge, do you have any fillings, crowns or veneers on your front teeth (the ones visible when you smile)?

Yes

No

Unsure

10

Are you currently breastfeeding or pregnant?

Yes

No

Unsure

11

Do you have loose teeth or red/swollen gums?

Yes

No

Unsure

12

Do you have any gum recession on the teeth that are visible when you smile?

Yes

No

Unsure

13

Do you have any questions about our whitening products or services?

14