The Smile Analysis
Are you self-conscious about your teeth or smile?
Yes
No
Would you like to change anything about the appearance of your teeth or smile?
Yes
No
Does the appearance of your smile inhibit you from laughing or smiling?
Yes
No
Are any of your teeth yellow, stained or somewhat discolored?
Yes
No
Would you like your teeth to be whiter?
Yes
No
When being photographed, do you smile with your lips closed instead of flashing a full smile?
Yes
No
Do you have any prior dental work that appears unnatural?
Yes
No
Do you see any pitting or defects on the surfaces of your teeth?
Yes
No
Do any of your teeth appear too small, short, large or long?
Yes
No
Do you have a "gummy" smile (too much of your gums show when smiling)?
Yes
No
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Basic Info
Do you have any crowns or bridges that appear dark at the edge of your gums?
Yes
No
Do you have any gray, black or silver (mercury) fillings in your teeth?
Yes
No
Are your gums red, sore, puffy, bleeding or receded?
Yes
No
Do you have any gaps or spaces between your teeth?
Yes
No
Are any of your teeth turned, crooked, or uneven?
Yes
No
Are you missing any teeth?
Yes
No
Are the edges of any teeth worn down, chipped or uneven?
Yes
No
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Your Information
Contact Name
*
E-mail
*
Phone
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