Cosmetic Questionnaire 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 Submit Your request has been sent -- we will be in contact with you shortly. Please make sure ALL fields are filled out correctly.
