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Digital Smile Makeovers

Cosmetic Dentistry Questionnaire

Please fill out the following form to help us evaluate your smile.

Would you like your teeth to be whiter?
Are you missing any teeth?
Do you have any gaps or spaces between your teeth?
In terms of teeth length, do you feel your teeth are?
Are any of your teeth turned, crooked, or uneven?
How do you feel about the amount of gum tissue that shows when you smile?
Are your gums red, sore, puffy, bleeding, or receded?
Are you self-conscious about visible dark or silver (mercury) fillings when you smile?
Are the edges of any teeth worn down, chipped, or uneven?
Do you have any crowns or bridges that appear dark at the edge of your gums?
Are you self-conscious about visible dark or silver (mercury) fillings when you smile?
Do you have any crown or bridges that appear dark at the edge of your gums?
Does the appearance of your smile repress you from laughing or smiling?
When photographed, do you smile with lips closed instead of flashing a full smile?
Are you self-conscious about your smile?
To receive a personalized response to your smile analysis, please let us know how you would like "Allie" our Patient Care Specialist to contact you:

Thanks for submitting!

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