LIVE SCAN

REGISTRATION FORM

After completing the registration form below, you will be sent a unique ID number via text message. Please present the ID to the agent who will be scanning your teeth. This ID is used to match your scan with your account!

Female

Male

A confirmation email will be sent to this account

Name

Last name

Cell phone

You will receive a confirmation text with your Scan ID

MM/DD/YYYY - Birthday of the person being scanned

+ Add apartment etc Use autocomplete

Start typing your mailing address...*

Type your mailing address and the form will show you auto-complete options

Address

Country

City

Post Code

State

Apartment, suite, unite etc. (optional)

Which products are you most interested?

Please select all the options that you may be interested in (now and in the future)

ProShield™ Custom-fitted Sports Mouth Guards
Custom-fitted Teeth Whitening Trays
Custom-fitted Night Guards (for teeth grinding/clenching)
Clear Retainers
Clear Aligners (for straightening teeth)

Select your primary sport.

If you play multiple sports, please just select your primary sport where you will use your mouth guard.

YOU'RE IN!

Dear ,
we have confirmed your account registration with Smile Brilliant / ProShield!
Your registration ID is LS288546 Please present this ID to your agent before they begin your scan. Login details have been emailed to your email address at .

REGISTRATION FORM

CONTACT INFORMATION

Which products are you most interested?

Select your primary sport.

YOU'RE IN!