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I am:Please SelectAn adult seeking treatment for myselfA parent / caregiver seeking treatment for my teenA teen seeking treatment for myselfA parent/caregiver seeking treatment for my child (ages 7 and above)

My smile priorities: *Please SelectGrinding and clenching my teethMy bite feels differentHaven’t worn my retainer consistentlyI’ve noticed airway concernsTense chewing musclesBreathing/sleep troublePlease Select Smile PrioritiesCrooked teethJaw seems small or narrowProtruding front teethEarly or late loss of baby teethTeeth not coming in evenlyMouth breathing or snoring at nightSpeech concerns (lisping or tongue position)Trouble chewing or jaw discomfortThumb sucking or oral habitsGaps between teeth
My primary goal is to treat: *

First Name *
Last Name *
Email *
Phone *
Parent’s name, if applicable
Age of the patient
Upcoming event, if applicable
How should we contact you? *PhoneEmail