Smile Assessment

Welcome to the Online Smile Assessment!* This field is required.Let's start by taking your name :-)

First name

Surname

First of all, are you a new or existing patient?* This field is required.

New

Existing

Out of 10, how happy are you with your smile?* This field is required.

Very unhappy

Very happy

Are there any aspects of your smile that you would like to improve?* This field is required.

Tooth colour

Tooth alignment (how straight they are)

Tooth shape or size

Tooth surface (texture/how worn they are)

Gaps or spaces between teeth

Gum health

Other

Are you currently experiencing any problems or pain?Please leave as much detail as possible.

Is there a special occasion motivating you to seek dental treatment?eg. you're getting married in June 2026 / school reunion in 6 months etc

How soon would you be looking to start treatment?* This field is required.

ASAP!

Within 3 months

3-6 months

I'm just looking at options now

Are there any treatments that you may be interested in?Tick all that apply :-)

Cosmetic Bonding

Teeth Straightening/ Invisalign

Veneers/Crowns

Whitening

Dentures

Implants

Other

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

Your date of birth* This field is required.

Date

Any other info we need to know?Feel free to elaborate on anything we've gone through - the more detail you give, the better we can help you!

Say Cheese!* This field is required.We'll show you examples of the shots that we need, then you'll have the option to add a photo. Make sure you have good lighting and don't hold the camera too close!

Proceed to photos

I can't add photos right now - send me a link so I can do this another time

Photo 1 - Close up smiling with teeth squeezed together

Close up smiling with teeth squeezed together* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Photo 2 - Upper teeth, head back and mouth wide open

Upper teeth, head back and mouth wide open* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Photo 3 - Bottom teeth, head down and mouth wide open

Bottom teeth, head down and mouth wide open* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Photo 4 - Right smile, teeth squeezed together

Right smile, teeth squeezed together* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Photo 5 - Left smile, teeth squeezed together

Left smile, teeth squeezed together* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Photo 6 - Full face, big smile

Full face, big smile* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Photo 7 - Profile, gentle smile

Profile, gentle smile* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Let's make sure we have all your details* This field is required.We will contact you by phone or email once you have completed this form

First name

Surname

Please enter your email

Please enter your phone

Your Availability* This field is required.This will help us to contact you and/or to find suitable appointments for you. Please note that the practice opens at 12pm on Tuesdays.

🔒 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?* This field is required.

Yes - I am happy for you to contact me regarding my enquiry