Client Evaluation - Teeth Whitening
by Beautiful Bright Smile
Street Address Line 2
State / Province
Postal / Zip Code
How did you hear about us?
Have you ever had an adverse reaction to:
Have you recently had any dental restorations placed (crowns, bridges, fillings, implants or partial dentures)?
Are you scheduled for or anticipating any restoration work in the next 6 months?
Have you recently had oral surgery?
When was your last dental cleaning (approx)?
Have you used whitening products in the past?
If yes, did you see any results?
Did you have any negative side effects?
Do you have any areas of gum recession, or sensitive gums?
Are you pregnant or nursing?
Do you suffer from diabetes for epilepsy
Before and after pictures are always completed with our treatments. Do we have your permission to post your pictures to social media, the website, and as possible educational purposes?
Is there any other information we should know?
Should be Empty:
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