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Cosmetic Questionnaire
In order to provide you a virtual consultation and assess your dental concerns, please submit your information below.
Your information will be securely sent back to our team to evaluate.
1. How would you rate your smile?
2. Do you prefer to have brighter teeth?
3. While smiling, are you happy with how much your teeth show?
4. In terms of the length of your teeth, do you feel that your teeth are?
5. Would you like to change the angle or orientation (slanted or rotated) of any of your teeth?
6. Do you have any staining or mottling you'd like to have removed?
7. How do you feel about the amount of gums that shows when you smile?
8. Do you think the gum tissue around your teeth is symmetrical?
9. Do you have any dark crown margins that are visible or inflamed gums around a crown or filling?
10. Are you concerned about wear or chipping on your front teeth?
11. Are you self-conscious about visible dark metal fillings when you smile?
12. Do you have sensitive teeth due to gum recession or discoloration of teeth at gum line visible when you smile?
13. If you could make any changes to the look of your smile, what changes would you make?
Smile & Profile
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Overbite & Overjet
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Upper Arch & Lower Arch
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Right Bite & Left Bite
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First Name
Last Name
Date Of Birth
Phone
Email
Preferred Contact Method
Preferred Contact Time
Notes, Comments, or Questions
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