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My Name

First Name Last Name

Age

Grade

Our entire team is here for you! If you have any questions, let us know, if we don’t have the answer we will find someone who does.

TELL US HOW YOU FEEL ABOUT YOUR SMILE AND TEETH, WHAT YOU LIKE OR DON'T LIKE:

WOULD YOU LIKE TO SHARE WITH US SOME OF YOUR FUTURE PLANS AND GOALS?

WHAT IS THE FIRST THING PEOPLE NOTICE ABOUT YOU?

HOW DO YOU FEEL ABOUT THAT?

WHAT ARE YOUR FAVORITE TYPE OF MUSIC OR WEBSITES?

QUESTIONS YOU HAVE FOR THE STAFF OR DOCTOR?

ANYTHING ABOUT YOU THAT YOU THINK IS IMPORTANT FOR US TO KNOW:

PLEASE FEEL FREE TO ADD ANY COMMENTA OR SUGGESTIONS ON THE BACK OF THIS FORM. ALL COMMENTS ARE APPRECIATED AND WILL HELP US MAKE THIS FORM BETTER IN THE FUTURE