Patient Information

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Check All That Apply To You *

Gaps or Spaces

Gums Hide Teeth

Crooked Teeth

Worn or Chipped Teeth

Discolored Teeth

Missing Teeth

Old Ugly Dentistry

Metal Clasps Showing

Teeth Too Short/Small

Loose Dentures/Partials

I Need A Regular Cleaning

Decayed Teeth

Other (Please describe):

Additional Comments

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Where did you hear about us?

Current Patient

Thomasville Magazine

Tallahassee Magazine

SW Georgia Living Magazine

TV Ads

Newspaper

Other

If other, please include here:

Oppenheim Center for Cosmetic, Restorative & General Dentistry

207 East Jackson St.
Thomasville, GA 31792
Phone: (229) 226-1631
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