Submit your responses
for a chance at a 

Would This purchase be a:


3 Things I Hear Most (select any that describe you):

This will completely change my lifeI have a special event coming soonThis would restore my self esteem

4 Questions I always ask everyone on this page

If not Us, then Who?

If not Now, then When?

What's it really costing you not to smile?

Can you afford to wait?




Cell Phone

Full Address

Upload a Full Face Photo
Upload a Close-Up Photo
I hereby authorize the use of my likeness and/or story for any and all purposes. I agree that Brighter Image Lab will not be held liable for any loss, damages of injury associated with applying for, accepting, or using their new smile. I agree that Brighter Image Lab retains the right to make any and all decisions as to the nature of the products or services being rendered and/or to cancel any agreement or work being done for any reason whatsoever. By submitting this form, I confirm I have read and agree to all of the terms & conditions.