Candidate for Teeth Whitening

1. Your full name

2. Please upload a picture of your teeth (jpg, png, gif, pdf)

3. Please indicate year of birth

4. Your phone number

5. Your email

6. This is my first teeth whitening

7. If no, please specify the brand, at a dentist, home kit, toothpaste ... etc.

8. I am an adult

9. I am pregnant

10. I breastfed my child

11. I have sensitive teeth

12. I remove the tartar once a year

13. I drink a lot of sodas or energy drinks

14. I use fluoride toothpaste

15. I want to whiten my teeth

16. I have no oral problems

17. I am healthy

18. I use a hard toothbrush

19. Please specify the expected whiteness

20. The name of the institute you are referring to or the default location

21. My availabilities: days, dates, hours

I read and understood