York Place Dental Smile Assessment
Help us to tailor your consultation to you by completing the following form. Your details are secure and will only be used to help plan your visit.
Out of 10, how happy are you with your smile?
*
1
2
3
4
5
6
7
8
9
10
Are there any aspects of your smile that you would like to improve?
*
Tooth colour
Tooth alignment (how straight they are)
Tooth surface (texture/how worn they are)
Gaps or spaces between teeth
Gum health
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How soon would you be looking to start treatment?
*
ASAP!
Within 3 months
3-6 months
I'm just looking at options now
Are there any treatments that you may be interested in?
Cosmetic Bonding
Teeth Straightening/ Invisalign
Veneers/Crowns
Whitening
Dentures
Implants
Other
Is there a special occasion motivating you to seek dental treatment?
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Are you currently experiencing any problems or pain?
Is there anything that may prevent you from getting dental treatment?
Fear or anxiety
Cost of treatment
Time constraints
Embarrassment about my teeth
Travel concerns
Uncertainty about results
Other
Any other info we need to know?
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Next
Now we'll ask you for some photos of your teeth for our dentists to review.
Tips for Great Smile Photos **Stand in good light, facing a window** Use a plain background** Keep the camera at mouth level and the image sharp**
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Let's go!
Close up smiling with teeth squeezed together
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Upper teeth, head back and mouth wide open
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Next
Bottom teeth, head down and mouth wide open
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Right smile, teeth squeezed together
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Left smile, teeth squeezed together
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Full face, big smile
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Profile, gentle smile
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Name
*
First Name
Last Name
Date of birth
*
 -
Month
 -
Day
Year
Date
Email
*
example@example.com
Phone number
*
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Your Availability
*
Â
9am-12pm
12pm-4pm
4pm onwards
Mon
Tues
Wed
Thurs
Fri
🔒 We respect your privacy. Your information is stored securely and only used to follow up on your enquiry. Do you agree to be contacted by phone, email, or SMS?
*
Yes - I am happy for you to contact me regarding my enquiry
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