Divign Dental Aligners: Questionnaire
1. I am:
An adult considering Divign Dental Aligners
A teen considering Divign
An adult considering Divign for my child
Other
2. Which best describes the orthodontic therapy you've had in the past?
Braces
Orthodontic aligners
Retainers
Palate expander
Removable device
Headgear
Space maintainer
Never had orthodontic treatment
Other
2a. If you've experienced dental braces relapse (some teeth have moved) - when did you first become aware of the problem?
less than 1 year
1-5 years
5-20 years
20+ years
never had orthodontic therapy
never had any dental braces relapse
my teeth have shifted, but I've never had orthodontic therapy
not applicable
Other
3. Do you have all of your adult teeth (except for wisdom teeth)?
Yes
No
Not sure
Other
4. What do you hope to achieve from Divign Dental Aligner Therapy? (please select as many as you'd like)
Healthier gums and bone
More even bite
Healthier teeth
Less crowding
Straighter teeth
Reduce the overbite
Make brushing easier
Reduce underbite
Make flossing easier
Reduce staining and plaque buildup
Close gaps
Improve my smile
Increased confidence
Improve my profile
none of the above
Other
5. How many times per day do you brush?
1
2
3 or more
less than 1
6. How many times per day do you floss?
0
1
2 or more
7. Which statement(s) do you agree with?
A healthy mouth is an important part of my overall health.
A beautiful smile is very important to me.
My primary goal is to have straight teeth, but, general dental health is important, too.
My primary goal is to have excellent dental health
None of the above
Other
8. Do you have any orthodontic insurance coverage?
Yes
No
I don't know
Other
9. Can you benefit from a health savings account (HSA) flexible spending account (FSA)?
Yes
No
I don't know
Other
10. If everything works out, when would you like to start Divign?
Immediately
Next month
In the next 6 months
Next January
As soon as I can arrange the finances
Not sure
Other
11. How much research have you done?
Just started
Spoke with my dentist about Orthodontic Aligners but have not had an evaluation
Have an appointment scheduled for an evaluation
Had an Orthodontic Aligner consultation and would like a second opinion
Ready to schedule an appointment to start Divign Dental Aligner treatment
Other
12. Have you ever been told that you were not a candidate for Orthodontic Aligners?
Yes
No
Sort of
Not sure
Other
13. If you have had an Orthodontic Aligner-Specific Consultation, was your treatment classified as:
Standard
Advanced
Complex
I was told I couldn't have Smile Direct Club care
Not sure
Other
14. Would you be opposed to having your teeth whitened by an oral antiseptic agent during the therapy?
Yes
No
Not sure
Other
Full Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Print Form
Submit to Dr. Davis
Clear Form
Should be Empty: