Whitening for Life - New Patient Package

1. How can we specifically help you?

Cosmetic Smile Design
Laser Whitening
Family Dentistry
Periodontics
X-Rays
Orthodontics
All of the above

Please tell us more.

2. What's most important to you in the dental care you receive?

3. Do you have a dentist currently? Yes No

4. Did you know that you can have the beautiful smile you deserve in as little as two visits? When are you planning to have cosmetic work done on your smile?

3 Months?
6 months?
Less than a year?
More than a year?

Do you like your smile? Yes No

If you discovered an easy, safe and natural way to lighten your teeth would you be interested? Yes No

Through major advances in dentistry, we can instantly staighten, upper and lower teeth, close gaps, correct chips and irregularly shaped teeth in as little as two visits. Does this interest you?
Yes No

5. Please tell us about yourself:

Name:
Telephone:
e-mail:

6. May we contact you from time to time about new advances in our practice, special offers and how best to serve your dental needs.
Yes No

7. How would you like to be contacted?

E-mail:
Telephone:
Mailing Address: (Please enter Street, City, State, & Zip)

Please Note: E-mail is not a secure form of information and we
cannot guarantee the privacy of your message