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Evening Phone:
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Interests and Concerns - Please Check All That Apply
Complete Cosmetic Evaluation
Whitening
Spaces, Crowding, Missing Teeth
Injuries, Chips, Decay
Issues with Existing Dental Work
Tipped or Twisted Teeth
Single Tooth Implant
Dentures and/or Implants
Tooth Size and Proportion
Teeth Appear Long or Short
Some Teeth Are Large or Small by Comparison
Midline Off
Slanted Smile
Edges of Upper Teeth Not Following Contours of Lower Lip During Smile
Gum Cosmetics - Height, Shape, Symmetry, Visibility, Health
Have You Ever Considered Orthodontics? Yes No
Any Other Helpful Information
   


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