Bride Smiles Pre-Consultation

We look forward to helping to ensure that you and your smile shine bright on your big day!

All information is strictly private and confidential & will be used only for your Kaye Dentistry Consultation.

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* 1. Your Name

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* 2. Your E-mail Address

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* 3. Your Telephone #

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* 4. Are you the ...

Bride

Groom

Member of Wedding Party

Bride

Groom

Member of Wedding Party

If Groom or Wedding Party Member, what is the Bride's Name?

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* 5. Wedding Date

The big day is

Date

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* 6. Have you had ...

	Yes	No
Professional Teeth Whitening?	Professional Teeth Whitening? Yes	Professional Teeth Whitening? No
A Dental Cleaning & Exam in the past 6 months?	A Dental Cleaning & Exam in the past 6 months? Yes	A Dental Cleaning & Exam in the past 6 months? No
Dental X-rays in the past 6 months?	Dental X-rays in the past 6 months? Yes	Dental X-rays in the past 6 months? No

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* 7. Do you have ...

	Yes	No	Not sure
Veneers	Veneers Yes	Veneers No	Veneers Not sure
Cosmetic Bonding	Cosmetic Bonding Yes	Cosmetic Bonding No	Cosmetic Bonding Not sure
Tooth Colored Fillings	Tooth Colored Fillings Yes	Tooth Colored Fillings No	Tooth Colored Fillings Not sure

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* 8. Do you have ...

	Yes	No
Sensitive Teeth	Sensitive Teeth Yes	Sensitive Teeth No
Concerns about Teeth Color /Shade	Concerns about Teeth Color /Shade Yes	Concerns about Teeth Color /Shade No
Other Concerns about your Teeth or Gums	Other Concerns about your Teeth or Gums Yes	Other Concerns about your Teeth or Gums No

What are your Concerns?

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* 9. Do you drink Coffee, Tea, Red Wine, or Soda?

Yes

REMINDER:

Snap a photo of your biggest smile and send it to .... drgoldstein@kayedentistry.com

Our doctors will be contacting you soon. We look forward to meeting you!

Question Title

* 1. Your Name

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* 2. Your E-mail Address

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* 3. Your Telephone #

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* 4. Are you the ...

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* 5. Wedding Date

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* 6. Have you had ...

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* 7. Do you have ...

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* 8. Do you have ...

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* 9. Do you drink Coffee, Tea, Red Wine, or Soda?

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