Gentle Gum Checker

1

Do you think your gums are swollen?* This field is required.

YESNO

2

Do you notice any bleeding when you brush your teeth?* This field is required.

YESNO

3

Do you have gaps between your teeth or gum recession?* This field is required.

YESNO

4

Do you think (or has anyone once told you) that you have bad breath?* This field is required.

YESNO

5

Do you suffer from diabetes or any heart condition?* This field is required.

YESNO

6

Do you feel that you have one or more wobbly teeth?* This field is required.

YESNO

7

Name

First Name

Last Name

8

Email

example@example.com

9

Phone Number