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We love inspiring healthy + confident smiles!
Let's find out if you're a candidate for professional teeth whitening...
13
Questions
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1
Name
*
This field is required.
First Name
Last Name
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2
Email
*
This field is required.
example@example.com
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3
Phone Number
Area Code
Phone Number
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4
Birthdate
-
Date
Year
Month
Day
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5
Approximately how long since your last check up with a dentist?
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6
Approximately how long since your last dental cleaning?
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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.
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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....
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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
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10
Are you currently breastfeeding or pregnant?
Yes
No
Unsure
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11
Do you have loose teeth or red/swollen gums?
Yes
No
Unsure
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12
Do you have any gum recession on the teeth that are visible when you smile?
Yes
No
Unsure
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13
Do you have any questions about our whitening products or services?
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14
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