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What's your first name?


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What's your last name?


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What gender do you identify as?


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When's your birthday?
(Only so we can send you something nice on your special day 🎁)


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How often do you brush your teeth?


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What kind of toothpaste do you use?


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Do you floss?


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Does drinking ice water or eating ice cream hurt your teeth?


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Do you have sensitive teeth?


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Do teeth whitening products usually cause you pain?


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Do you have any cavities or have you recently had cavities filled?


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Do you grind your teeth?


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Do you have any gum infection or inflammation we should know about?


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How often do you eat or drink foods that stain your teeth?

Examples include coffee, red wine, marinara sauce (aka all the good foods 😫)


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Do you smoke cigarettes or cigars?


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What shade is your teeth currently?


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How did you first hear about us?



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What's your email


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