Smile Evaluation Form:

1. Are you happy with the way your teeth appear when you smile?       YES      NO

2. If NO, what is it about your smile you would like to change?

________________________________________________________________________________________________________________________________________________

3. Are you concerned about the level of whiteness of one or more         YES      NO

of my teeth.

3. I am concerned about the position or alignment of one or more         YES      NO

of my teeth.

4. I am concerned about the shape of one or more of my teeth.             YES      NO

5. In social situations, I am somewhat embarrassed by my teeth              YES      NO

or my smile.

6. There are some things about my upper front teeth that I would          YES      NO

like to change.

7. There are some things about my lower front teeth that I would          YES      NO

like to change.

8. I have old fillings or previous dental work that is no longer                 YES      NO

or has never been satisfactory to me.

Please use the space below to indicate any other problems, concerns or questions. We will listen attentively to your concerns so that we can present you with the best possible treatment options. ~Thank you!

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________