Composite Veneer Consultation Form

Composite Veneer

Consultation Form
Client Intake

Complete this form if you're interested in COMPOSITE VENEERS or any composite services ONLY!! Please input all of your correct and accurate information so that someone on our team can contact you accordingly. Thank you! First step to a SMILE TRANSFORMATION. Everyone isn't eligible to receive these services. If you have multiple missing teeth in a row, cavities, any dental disease, misaligned teeth, crowding, crooked and other contradictions unfortunately we aren’t able to do your composite veneers. PLEASE DO NOT COMPLETE THE FORM IF YOU HAVE ANY OF THE ABOVE CONTRADICTIONS. Thank you
Name

First NameLast Name
Birth Date

MonthDayYear
Phone Number
Email
example@example.com
Gender?
Cosmetic Procedure Details
Have you had a recent teeth cleaning? If not, a cleaning needs to be done before receiving this service..
Do you have any dental contradictions?

• GUM Disease

• Periodontal Disease

• Crowns

• Missing Teeth

• Poor Oral Hygiene

• Gingivitis

• Inflamed gingiva(gums)

etc.
If so write your contradictions below. Some contradictions may disqualify you from receiving composite veneers - Type a label
Do you have any concerns with your teeth that you want fixed? blanks
What service of composite bonding? * Prices shown are regular pricing. May not reflect current sale price.
What shade of composite would you like?
Do you have any caps, crowns, fillings on the surface of your teeth? If so this could disqualify you from receiving composite veneers. Please let us know during consultation.
If so, which teeth have bonding?
Are you completing the form for the BRING A FRIEND DEAL? If so enter the other persons name?
How did you hear about us?
If someone referred you, whats there name? If you heard about us through social media, whats your social media name?
Upload 4 Clear Photos UP CLOSE SHOWING ONLY YOUR TEETH. • FOLLOW The Example Above. • Please make sure the lighting is bright!
FRONT (show your top and bottom teeth)
LEFT SIDE(from the side)
Mouth OPEN
RIGHT SIDE ( from the side)
Smile and bite all the way down as if you’re taking a selfie. Show just your teeth
Acknowledgement and Waiver
Before submitting please confirm all your information is correct. DO NOT schedule an appointment without a response. Someone will reach out to you via text within 2-4 business days. If you don’t receive a response within that time frame please reach out to us. Everyone isn’t eligible for this service. You'll receive a response rather you are or aren't a good candidate. If you have any questions you can contact us via email: qualityysmiles@gmail.com or phone (313)903-2822
Should be Empty:

Composite Veneer

Client Intake

Cosmetic Procedure Details

Acknowledgement and Waiver