Am I a candidate for professional whitening?

You can always press Enter⏎ to continue

We love inspiring healthy + confident smiles!

We love inspiring healthy + confident smiles!

Let's find out if you're a candidate for professional teeth whitening...

13Questions

1
Name
First Name
Last Name
2
Email
example@example.com
3
Phone Number
Area Code
Phone Number
4
Birthdate
Date
Year
Month
Day
5
Approximately how long since your last check up with a dentist?
6
Approximately how long since your last dental cleaning?
7
On a day to day basis, how sensitive are your teeth?
Not sensitive at all.
A little sensitive.
Moderately sensitive.
Very sensitive.
Not sensitive at all.
A little sensitive.
Moderately sensitive.
Very sensitive.
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....
Huge
Large
Normal
Small
Ok
Ok
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?
Huge
Large
Normal
Small
Ok
Ok
14
Tags
Todo
In Progress
Done
Should be Empty:

Question Label

1 of 14See AllGo Back

Save & Continue Later

Your form is saved successfully!

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Please enter a valid email address.

Something went wrong while saving your answers. Please try again.

Email has been sent successfully.

Save your progress

OR

Already have an account? LOGIN

Skip Create an Account

Save your progress

Name

Email Address

Password

I agree to theTerms of ServiceandPrivacy Policy

Your form submission has been saved as a draft.

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Save your progress

OR

Username or email

Password

Forgot Password?

Your form submission has been saved as a draft.

We’ve sent you an email with a link to complete your submission.