Will This Work For Me? Do You Qualify For Clear Aligners For $2599? Only pay for what you need with Str8 Teeth!1. Are You Over 18 Years Old?*YesNoSorry. You must be over 18 years of age to complete this assessment. Please have a parent of guardian complete this form on your behalf.2. Have You Used Any Clear Aligners or Braces Before?*YesNo3. Which Picture Best Describes The Crowding In Your Mouth?*Mild CrowdingModerate CrowdingSevere Crowding4. Which Picture Best Describes The Spacing In Your Mouth?*Mild SpacingModerate SpacingSevere Spacing5. Choose the option that best describes your biggest concern with your smile:*Please SelectFix Spacing IssueFix Crowding IssueFix Bite ProblemGenerally Straighter TeethOther (Please Specify)My Biggest Concern6. Do You Have Any Of The Following?* Crowns Veneers Bridges Implants Dentures Missing Teeth None Of The Above 7. Why Are You Thinking About Straightening Your Teeth?*Please SelectBuild ConfidenceGetting MarriedNew JobJust Want Straighter TeethOther (Please Specify)Why I Want Straighter TeethYour Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Name Last Name Email* Enter Email Confirm Email Phone*Preferred Appointment Day*MondayTuesdayWednesdayThursdayFriday*MorningAfternoon
