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Brush n Brace Teen Dental
Brush n Brace Teen Dental
Brush n Brace Teen Dental
Brush n Brace Teen Dental
Brush n Brace Teen Dental

Teen Form

We'd Like To Get To Know You!

We have created this short form to help us give you the best care possible! The answers you give will be kept strictly confidential, this is between you and your doctor.
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​​​​​​​Form for teen to fill out

Do you have? (Check all apply)*

Let us know a little bit about you

Hobbies?

Social Media?

Favorite Show/Movie?

Favorite video game?

Favorite sports team?

Favorite Musician/Artist

Concerns?

(Check all that apply)*

Health Info

Do you? (Check all that apply)*