FF-04,Narayan krupa Avenue, Opp. Prernatirth Derasar, Satellite, Ahmedabad-15

+91 7567412412 theparikhsclinic@gmail.com

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Smile Now

1. Select Your Smile

1. Are You ? *

MaleFemale

2. Are You ? *

TeenAdult

3. Not Happy with? *

Size of The TeethShape of The TeethColor of The TeethShade of The TeethTeeth CrowdingAlignment of Teeth

4. Any Problem if you are Facing? *

CrowdingSpace between teethCross biteDeep bite

5. Do you feel low Confidence when you smile? *

YesNo

6. Do You Feel Conscious about your Breath? *

YesNo

7. Do you Feel Conscious when you get Clicked? *

YesNo

8. Upload a Selfie or a Smiling Picture for our Assessment : *

2. Personal Detail

First Name

Last Name

Email

Phone Number

Country

State

City

Your message (optional)

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