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?

_____________________________________________________________________________________

_____________________________________________________________________________________