Let's start the Smile Assessment!
Use this form to find out more about treatments at York Place Dental
Out of 10, how happy are you with your smile?
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1
2
3
4
5
6
7
8
9
10
Are there any aspects of your smile that you would like to improve?
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The colour of my teeth
The alignment/straightness of my teeth
The shape of my teeth (e.g. uneven, chipped, too small/large)
The surface of my teeth (e.g. rough, marks or patches on the teeth)
Gaps or spaces between my teeth
The overall health of my teeth and gums
Do you currently have any concerns about your teeth?
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Are there any treatments that you may be interested in?
Cosmetic Bonding
Teeth Straightening/ Invisalign
Veneers
Whitening
Dentures
Implants
ICON
Hygiene Therapy (scale and polish)
Other
When did you last see a dentist? (Don't worry - there's no judgement here)
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Within the last year
1-2 years ago
2-5 years ago
5-10 years ago
Over 10 years ago
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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?
Is there a special occasion motivating treatment? Do you have additional requirements?
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Title
Please Select
Mr
Mrs
Miss
Ms
Dr
Mx
Name
*
First Name
Last Name
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Email
*
example@example.com
Phone number
*
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Your Availability
*
Rows
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
Date
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Day
 -
Month
Year
Date
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