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Submit Your Information

You're on your way to a new smile! Upon completion of this form, you will receive a call from a Smile Republic representative to schedule your first appointment. We never share your information with third parties and your treatment is protected by doctor-patient confidentiality.

Step 1 of 4

Your Information
Address

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Select a Payment Plan

Don’t worry, payments on your plan don’t begin until after your initial consultation. Not a candidate or unable to begin treatment? No problem. The consultation fee is 100% refundable. After accepting treatment your consultation charge is applied to your treatment plan.

Step 2 of 4

Choose a Plan
Let your doctor know what plan you're interested in.
Only $49 due now
*Monthly price varies based on creditworthiness
Select Preferred Office

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Review

Review your selections then click Submit to start your journey to your new smile!

Step 3 of 4

Name
Email
Phone Number
Address 2
Address 2
Unit
City
State
Zip
Plan
Preferred Office

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Payment Information

Review your selections then click Submit to start your journey to your new smile!

Step 4 of 4

Payment Information
  I accept a one time charge of $49

By clicking next, your card will be charged $49
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