PATIENT CHECK INThanks for coming to Unbraced! Please complete this short form before your Invisalign scan. PATIENT INFOName* First Last Patient Date of Birth* MM DD YYYY Parent Name (If Child A Minor) Parent First & Last NameEmail* Phone*Address Zip Code* Health & ConsentWhat’s your biggest smile concern?* Crowded Teeth Overbite Underbite Crossbite Gap Teeth Open Bite Do you have a bonded retainer?* Yes No Do you have any crowns?* Yes No Do you have any bridgework?* Yes No Do you have an impacted tooth?* Yes No Do you have any veneers?* Yes No Do you feel any pain in any of your teeth?* Yes No Do you authorize us to administer a scan within your mouth?* Yes No EmailThis field is for validation purposes and should be left unchanged.
