Describe the color of your teeth
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Very white
Black/gray
Yellow
Somewhat white
Are all of your teeth the same color?
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Yes
No
Have you had a teeth whitening treatment before?
*
Yes, from a dentist
Yes, but it was a kit from the store
No, I have not
Which (if any) of these do you drink in a typical week?
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Coffee/Dark Tea
Soda
Wine
Do you currently use or have you used tobacco products?
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Yes
No
How Ready Do You Feel To Do Something About Your Situation?
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Somewhat Ready
Very Ready
I Need Something FAST!
Have you ever had a Teeth Whitening consultation before?
*
Yes
No
What Is Your Name?
*
What Is Your Best Email Address?
*
What Is Your Best Phone Number?
*