Are you suitable for Braces - Park Brace Clinic

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Form Title* This field is required.

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Airtable Card title* This field is required.

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What issue are you trying to solve?* This field is required.Choose as many as you like

A: Crooked and / or twisted teeth

B: Protruding Teeth (goofy)

C: Gaps between teeth

Other

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Please describe the issue you are trying to solve

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Is there a date you would like to have your teeth straightened by?e.g. I would like it ready for a wedding in June

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Are you happy with the colour of your teeth?* This field is required.Many of our patients take advantage of our teeth whitening services

YESNO

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Meet our Orthodontist, Dr Trishan Malhi

Dr Trishan Malhi has over 15 years experience in orthodontics, he has a Diploma In Primary Care Orthodontics awarded by Royal college of surgeons England, but more importantly Trishan does not limit your options of how to get your teeth straight to just one system or one philosophy.

Dr Trishan Malhi

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Have you visited your dentist in the last 12 months?* This field is required.

YESNO

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What is your name?* This field is required.

First Name

Last Name

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Which email address should we use to contact you?* This field is required.

example@example.com

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What is your phone?* This field is required.We will use this to discuss your options and invite you to a consultation if required.