YOUR SMILE ASSESSMENT
At Smile by Design, we believe your smile should feel as good as it looks - and be uniquely yours. Our team brings together expertise across cosmetic, general, and implant dentistry with one shared purpose: creating beautiful results through exceptional care. To help us tailor your consultation and understand exactly what you’re hoping to achieve, we kindly ask that you complete the smile assessment form before your appointment. Your insights make all the difference in designing the ideal treatment plan for you. We look forward to welcoming you and creating a smile you’ll truly love. Dr Michael and the Smile by Design Team
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please ensure all details are correct to recieve your smile assessment
Instagram Name
More about you...
The questions below are designed to provide me with more information about your smile
Why do you want to change your smile?
*
Why is now the right time to start your smile transformation journey?
*
1. Have you had teeth whitening done before?
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Yes
No
2. Have you had your teeth straightened before?
*
Yes
No
3. Have you had any cosmetic work done in the past?
*
Yes
No
What would you like?
This section is designed to help us better understand what you'd like to achieve with your smile
What are you interested in learning about? (tick all that apply)
*
Dental Implants
Porcelain Veneers
Composite Veneers
Invisalign (teeth straightening top and bottom)
Composite Edge Bonding
Teeth Whitening
Would you be interested in finance options?
0% interest and $0 deposit
No, I do not require finance
When were you hoping to get started?
*
Immediately
1-3 Months
3-6 Months
6-12 Months
Let's take a look at your smile!
In this next section we'll ask for you to upload several pictures of your teeth in order to complete a full smile assessment for you. Please use the pictures below as a guide
Picture 1 - Example Image
Picture 1 - Wide Smile
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Picture 2 - Example Image
Picture 2 - Smile with top and bottom teeth
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
How did you hear about Smile By Design?
*
Please Select
Friend or Relative
Google Search
Facebook
Instagram
Magazine
E-mail
Other
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