Patient Smile Evaluation
Your Name:Date:
Email:Phone Number:


To aid in our diagnosis and treatment of your esthetic concerns, please take a moment and answer the following questions. Please circle your answer. 

Yes No
Do you dislike the color of your teeth?
Do you have spaces between your teeth that bother you?
Do you have chips or uneven edges on your teeth?
Do you feel that your your teeth are too long or too short?
Do you have dark fillings that show when you smile?
Do your gums show too much when you smile?
Are your teeth crowded or crooked?
Do you have existing crowns or dental work you consider "ugly"?
Are you self-conscious of your teeth and/or smile?
Has anyone (Friend, Family member, etc..) ever suggested that you should have something done with your teeth or smile?
Do you avoid smiling when you have your picture taken?
Would you like to improve your existing smile?
Do you wish you had a "new smile"?

 

 

Place a checkmark next to which of the following are concerns you have regarding dental treatment to improve your smile: 

Fear of Treatment
Time of treatment concerns
Financial concerns
Distance to office
Not understanding treatment
Embarrassment
Other