Preferred Contact Method
  • Phone
  • Text
Preferred Time Of Contact
How would you rate your smile?
  • It's awesome! I love it!
  • It's OK (mild dissatisfaction).
  • I'm unhappy with the appearance of my teeth
  • I'm embarrassed to smile or show my teeth.
Do you prefer to have brighter teeth?
  • Yes
  • No
  • Indifferent
While smiling, are you happy with how much your teeth show?
  • Shows too much
  • Does not show enough
  • I'm unhappy with the appearance of my teeth
In terms of the length of your teeth, do you feel that your teeth are?
  • Too long
  • Too short
  • Just right
Would you like to change the angle or orientation (slanted or rotated) of any of your teeth?
  • Yes
  • No
Do you have any staining or mottling you'd like to have removed?
  • Yes
  • No
How do you feel about the amount of gums that shows when you smile?
  • Too much
  • Not enough
  • Just right
Do you think the gum tissue around your teeth is symmetrical?
  • Gums seem higher over some teeth
  • Gums seem symmetrical
Do you have any dark crown margins that are visible or inflamed gums around a crown or filling?
  • Yes
  • No
Are you concerned about wear or chipping on your front teeth?
  • Yes
  • No
Are you self-conscious about visible dark metal fillings when you smile?
  • Yes
  • No
Do you have sensitive teeth due to gum recession or discoloration of teeth at gum line visible when you smile?
  • Yes
  • No
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