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Patient's Name
Responsible Party's Name
Your Phone
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Your Email
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If feasible, which would you prefer?
Invisalign Clear Aligners
Clear Braces
Metal Braces
Would you prefer an in office or online virtual appointment?
In Office
Online Virtual Appointment
What days would work best?
Tuesday
Wednesday
Thursday
Friday
Saturday (appointment only - limited availability)
Mornings or Afternoons?
Mornings
Afternoons
Either
What is the best way to reach you to confirm your appointment?
Email
Mobile Phone # (Text)
Email and Text
Tell us your goals and what is most important to you about your smile.
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