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Name_______________________
Email:________________________
Please Tell Dr. Rodriguez
What you don’t like about your teeth
____ Crowding/Crooked teeth ____ Jaw joint pain
____ Spaces ____ Missing Teeth
____ Tooth Size ____ Dark Teeth
____ Gummy Smile ____ Speech promblems
____ Underbite ____ Overbite
____ Teeth are different colors ____ Ugly old crowns
Other__________________________________________________________
Iam interested in
____ 6 Month Brace
____ Teeth Whitening
____ Veneers
____ Other _______________________________________________________
Is there anything you would like Dr. Roriguez to know?
_____________________________________________________________________________________
_____________________________________________________________________________________
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