Client Intake & Waiver

Please complete this form accurately prior to your mobile whitening session. This information helps us ensure a safe and effective treatment tailored to your smile goals.

Intake form and waiver

First name*

Last name*

Email*

Phone*

Address*

Service Location Desired?

Why are we looking to whitenup?

Professional

Personal

Special Occasion

Other

Add details if need:

Which habits affect you most?

Coffee

Wine

Berries

Smoking

add details if needed:

Any sensitivities or issues we should be aware of?*

Which service interests you the most?*

30 min

60 min

90 min

Why did that service stand out to you as the best option?

YourSmileCO

Contact

Mat@yoursmileco.com
+1 (516) 581-3825
Serving all of Colorado

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