Tell us about yourself - Step 1 of 2

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Email *

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Why you would you like to straighten your teeth?I want to feel more confidentI want to improve my appearanceI think it is important for my careerI think it is important for my oral healthIt's for a special occasion Other

How old are you? *

• 20 and over
• 18 - 19
• Under 18

What is your main concern? *

• Crowded teeth
• Overbite
• Crossbite
• Spaced teeth
• Underbite
• Open bite

Have you seen a dentist in the past 18 months? *

• Yes
• No

Help us find a clinic near you *

Have you worn braces or aligners before? *

• Yes
• No

Do you have a fixed wire retainer on the back of your teeth? *

• Yes
• No

Would you like a phone consultation from Selfie? *

• Weekday morning
• Weekday afternoon
• Weekday evening
• Weekend morning
• Weekend afternoon
• Weekend evening
• No, I'll contact you on Line

Do you have any questions for us? Or anything we should know about?

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