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Smile Evaluation Form

Name

Date

What makes you least comfortable in a dental practice?

What makes you feel most comfortable in a dental practice?

What can we do to make your experience more comfortable?

Do you like the way your teeth look?

Yes

No

Explain

Are you happy with the color of your teeth?

Yes

No

Explain

Would you like your teeth to be whiter?

Yes

No

Explain

Would you like your teeth to be straighter?

Yes

No

Explain

Do you have space between your teeth that you would like to be closed?

Yes

No

Explain

Would you like your teeth to be longer?

Yes

No

If you would like them to be longer where would you like them to be longer?

Upper

Lower

Both

Do you like the shape of your teeth?

Yes

No

Explain

Do you have old silver fillings that you would like to replace with tooth-colored fillings?

Yes

No

Explain

Do you have missing teeth that you would like to replace?

Yes

No

Explain

If you could change anything about your smile, what would you change?

Would there be any reason, not to go ahead with any needed dental treatment?

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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