</noscript><!-- End Google Tag Manager (noscript) --><div class="d-flex flex-column flex-md-row align-items-center p-3 px-md-4 mb-3 bg-white border-bottom box-shadow"><h5 class="my-0 mr-md-auto"><img src="/packs/media/img/become_logo_Primary_black-613959ebd0c2b3bc06bcaa3ae10b63f3.png" /></h5></div><div class="container" style="padding-left: 30px; padding-right: 30px;"><div class="row"><div class="col-12"><h2 class="text-center text-lg-left text-md-left">Free 30-second Smile Assessment</h2><p class="text-center text-lg-left text-md-left">Take 30 seconds to answer these questions and find out if Become is right for you.</p></div></div><div class="row"><div class="col-12"><form data-parsley-validate="true" id="assessment_form" action="https://portal.become.my/assess-your-case" accept-charset="UTF-8" method="post"><input type="hidden" name="authenticity_token" value="TeMzbM5tdQqSc0RX+UpT0imAgDWBZXqX2wVoI1AlBCN8z4J9hKA3FK7z4uIWDU+IomyG1nYS4W/IaoV5VsBO8g==" /><div class="form-group"><label class="bold" for="#Name">1. What is your name?</label><input class="form-control" name="name" onclick="setValue('name');" placeholder="Name*" required="" type="text" /></div><div class="form-group"><p class="bold"> 2. Have you previously worn braces or invisible braces?</p><div class="form-check form-check-inline"><input class="form-check-input" data-parsley-errors-container="#errors-used-braces" id="inlineRadio1" name="used_braces" onclick="setValue('previously_worn_braces');" required="" type="radio" value="Yes" /><label class="form-check-label" for="inlineRadio1"> Yes</label></div><div class="form-check form-check-inline"><input class="form-check-input" id="inlineRadio2" name="used_braces" onclick="setValue('previously_worn_braces');" type="radio" value="No" /><label class="form-check-label" for="inlineRadio2"> No</label></div><div id="errors-used-braces"></div></div><div class="form-group"><label class="bold" for="#TeethCrowding">3. How’s your teeth crowding?</label><div class="form-group"><div class="crowding-selector row"><div class="col-md-6"><input id="CrowdingMild" name="crowding" type="radio" value="Mild" /><figure class="figure image-radio radio-crowding-mild"><img class="figure-img img-fluid rounded" onclick="setValue('crowding');" src="https://become.my/wp-content/uploads/2020/02/image_crowding_mild.jpg" /><figcaption class="figure-caption text-center">Mild</figcaption></figure></div><div class="col-md-6"><input id="CrowdingModerate" name="crowding" type="radio" value="Moderate" /><figure class="figure image-radio radio-crowding-none"><img class="figure-img img-fluid rounded" onclick="setValue('crowding');" src="https://become.my/wp-content/uploads/2020/02/image_crowding_moderate.jpg" /><figcaption class="figure-caption text-center">Moderate</figcaption></figure></div><div class="col-md-6"><input id="CrowdingExtreme" name="crowding" type="radio" value="Extreme" /><figure class="figure image-radio radio-crowding-extreme"><img class="figure-img img-fluid rounded" onclick="setValue('crowding');" src="https://become.my/wp-content/uploads/2020/02/image_crowding_extreme.jpg" /><figcaption class="figure-caption text-center">Extreme</figcaption></figure></div><div class="col-md-6 pt-md-5"><input id="CrowdingNone" name="crowding" type="radio" value="None" /><figure class="figure image-radio radio-crowding-none d-flex justify-content-center"><button class="btn btn-secondary btn-sm" onclick="setValue('crowding');" type="button">None</button></figure></div><div class="col-md-12" id="errors-crowding"></div></div></div></div><div class="form-group"><label class="bold" for="#TeethSpacing">4. How’s your teeth spacing?</label><div class="form-group"><div class="spacing-selector row"><div class="col-md-6"><input id="SpacingMild" name="spacing" type="radio" value="Mild" /><figure class="figure image-radio radio-spacing-mild"><img class="figure-img img-fluid rounded" onclick="setValue('spacing');" src="https://become.my/wp-content/uploads/2020/02/image_spacing_mild.jpg" /><figcaption class="figure-caption text-center">Mild</figcaption></figure></div><div class="col-md-6"><input id="SpacingModerate" name="spacing" type="radio" value="Moderate" /><figure class="figure image-radio radio-spacing-moderate"><img class="figure-img img-fluid rounded" onclick="setValue('spacing');" src="https://become.my/wp-content/uploads/2020/02/image_spacing_moderate.jpg" /><figcaption class="figure-caption text-center">Moderate</figcaption></figure></div><div class="col-md-6"><input id="SpacingExtreme" name="spacing" type="radio" value="Extreme" /><figure class="figure image-radio radio-spacing-extreme"><img class="figure-img img-fluid rounded" onclick="setValue('spacing');" src="https://become.my/wp-content/uploads/2020/02/image_spacing_extreme.jpg" /><figcaption class="figure-caption text-center">Extreme</figcaption></figure></div><div class="col-md-6 pt-md-5"><input id="SpacingNone" name="spacing" type="radio" value="None" /><figure class="figure image-radio radio-spacing-none d-flex justify-content-center"><button class="btn btn-secondary btn-sm" onclick="setValue('spacing');" type="button">None</button></figure></div></div></div></div><div class="form-group"><label class="bold" for="#ExistingConditions">5. Do you have any existing dental conditions?</label><select class="form-control" id="ExistingConditions" name="conditions" onclick="setValue('dental_condition');" required=""><option></option><option>Implants</option><option>Inflamed Gums</option><option>Missing Teeth</option><option>None of the above</option></select><small class="form-text text-muted">Select all that apply.</small></div><div class="form-group"><label class="bold" for="#StartEstimate">6. When were you hoping to get started?</label><select class="form-control" id="StartEstimate" name="start_estimate" onclick="setValue('get_started');" required=""><option></option><option>Right Away</option><option>In a few weeks</option><option>In a few months</option><option>Not Sure</option></select><small class="form-text text-muted">Most of our patients complete treatment in a few months on average.</small></div><div class="form-group"><p class="bold">All done! Now where should we send your results?</p></div><div class="form-group"><div class="col-xs-12 pb-2"><label class="sr-only" for="#Email">Email</label><input class="form-control" name="email" onclick="setValue('contact_details');" placeholder="Email*" required="" type="email" /></div><div class="col-xs-12 pb-2"><label class="sr-only" for="#Phone">Phone Number</label><input class="form-control" id="phone" name="phone" onclick="setValue('contact_details');" placeholder="123456789" required="" type="tel" /></div><div class="col-xs-12 pb-2"><label class="sr-only" for="#Phone">Phone Number</label><input name="photo_uploaded" type="hidden" value="false" /><input name="form_variant" type="hidden" value="assessment_form" /></div></div><div class="col-xs-12 pb-2"><button class="btn btn-primary btn-md assessment_submit" data-disable-with="Please Wait.." onclick="setValue('completed');" type="submit">Submit</button></div><hr /><script>function setValue(field) { window.dataLayer.push({ 'event': `LeadForm_${field}` }); console.log(field); }</script></form></div></div></div><footer class="footer"><div class="container"><p class="m-0 text-muted text-center">Become © 2021. All rights reserved.</p></div></footer><script src="/packs/js/file_upload-681e6b06b8f6503b2f32.js"></script><script src="https://cdnjs.cloudflare.com/ajax/libs/intl-tel-input/16.0.4/js/intlTelInput.js"></script><link href="https://cdnjs.cloudflare.com/ajax/libs/intl-tel-input/16.0.4/css/intlTelInput.css" rel="stylesheet" /><script>let input = document.querySelector("#phone"); if(input) { window.intlTelInput(input, { initialCountry: "auto", preferredCountries: ["my", "sg","ph"], ipinfoToken: "2a1005e87def07", geoIpLookup: function(callback) { $.get('https://ipinfo.io', function() {}, "jsonp").always(function(resp) { var countryCode = (resp && resp.country) ? resp.country : ""; callback(countryCode); }); }, utilsScript: "https://cdnjs.cloudflare.com/ajax/libs/intl-tel-input/16.0.4/js/utils.js" }); }</script><script>function setValue(field) { window.dataLayer.push({ 'event': `LeadForm_${field}` }); console.log(field); }</script></body></html>