Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Do you prefer weekday or weekend appointments? *

Weekdays

Weekends

Either

What time of day works best for you? *

Morning

Afternoon

Evening

Where would you like to get the treatment done? *

In-Studio (Toronto)

Mobile (we come to you)

What is your location? (if you selected mobile)

Please let us know where you would like to have your treatment done

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

When was your last professional dental cleaning? *

Less than 6 months ago

6-12 months ago

Over a year ago

Do you currently experience any of the following? (Check all that apply) *

Bleeding gums

Tooth sensitivity (hot, cold, sweet, or acidic foods/drinks)

Bad breath

Gum inflammation or discomfort

Loose teeth

Stains on teeth

Other

Have you been diagnosed with gum disease (e.g. gingivitis or periodontitis)? *

Yes

No

Unsure

Are you experiencing any tooth or gum pain currently? *

Yes

No

Do you have dental insurance? *

Yes

No

Do you have any medical conditions we should be aware of (e.g., diabetes, heart conditions, pregnancy)? *

Yes

No

Are you taking any medications or supplements? *

Yes

No

Do you have any allergies (e.g. latex, medications)? *

Yes

No

By checking below, I acknowledge that I have read and agree to the cancellation policy *

I agree

By checking below, I understand that it is my responsibility to confirm my coverage before my appointment

I understand

Would you like to take advantage of 20% off their whitening if combined with a dental cleaning *

Yes

No

By checking yes, I acknowledge that I have read and understand the above information *

Yes