Are any of your teeth yellow, stained or somewhat discolored? *

Yes

No

Would you like your teeth to be whiter? *

Yes

No

Do you have any gaps or spaces between your teeth? *

Yes

No

Are any of your teeth turned, crooked, or uneven? *

Yes

No

Are you missing any teeth? *

Yes

No

Do you see any pitting or defects on the surfaces of your teeth? *

Yes

No

Are the edges of any teeth worn down, chipped or uneven? *

Yes

No

Do any of your teeth appear too small, short, large or long? *

Yes

No

Do you have any prior dental work that appears unnatural? *

Yes

No

Do you have any crowns or bridges that appear dark at the edge of your gums? *

Yes

No

Do you have any gray, black or silver (mercury) fillings in your teeth? *

Yes

No

Do you have a "gummy" smile (too much of your gums show when smiling)? *

Yes

No

Are your gums red, sore, puffy, bleeding or receded? *

Yes

No

Does the appearance of your smile inhibit you from laughing or smiling? *

Yes

No

When being photographed, do you smile with your lips closed instead of flashing a full smile? *

Yes

No

Are you self-conscious about your teeth or smile? *

Yes

No

Would you like to change anything about the appearance of your teeth or smile? *

Yes

No

Name *

First Name

Last Name

Phone

(###)

###

####