What specific concerns do you have about your smile currently?

Crooked teeth

Overcrowding

Gaps between teeth

Overbite or underbite

Jaw alignment issues

Difficulty in chewing or speaking

Please select all that apply

What are your primary goals for orthodontic treatment?

Improve overall appearance

Correct bite issues

Enhance oral hygiene

Boost confidence

Resolve jaw pain or discomfort

Prepare for other dental treatments

Please select all that apply

Have you ever had orthodontic treatment before?

Yes, braces

Yes, Invisalign or clear aligners

Yes, other treatments

No, never had orthodontic treatment

Were you satisfied with the results of your previous treatment?

Completely satisfied

Somewhat satisfied

Neutral

Somewhat dissatisfied

Completely dissatisfied

What is your preferred treatment duration?

Shortest possible time (6-12 months)

Moderate (12-18 months)

Comprehensive treatment (18-24 months)

Flexible/open to recommendation

Which treatment method are you most interested in?

Braces

Invisalign

Open to recommendation

Unsure

Do you participate in any activities that might impact your treatment choice?

Contact sports

Playing a musical instrument

Public speaking

Professional performances

Modeling or acting

None of the above

Please select all that apply

Great! Now, let us know where to send your results.

First Name *

Last Name *

Phone *

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