Tell us about your top frustrations with your smile.

(Check the following that apply. Be honest! Remember, we're not concerned with what you have done in the past, rather where you are today so we can tailor the program to meet your needs.)

Tell us about your fears when it comes to the dentist.

Rate the following on a scale of 1 to 5!

1 = Extreme Challenge
2 = Very often a challenge
3 = Occasionally a challenge
4 = Rarely a challenge
5 = Never a challenge

Please tell us how to contact you in regards of your application.