Patient Survey

Please complete the form below.

Name
E-Mail
Phone
What is the best day and time to contact you?
1. Do you like the way your teeth look? Yes No Explain
2. Do you like the shape of your teeth? Yes No Explain
3. If there were a simple, inexpensive way to whiten your teeth,
would you be interested? Yes No Explain
4. Would you like any spaces in your teeth closed? Yes No Explain
5. Would you like your teeth to be longer? If so, upper or lower? Yes No Explain
6. Would you like your teeth to be straighter? Yes No Explain
7. Do you have missing teeth you would like to have replaced? Yes No Explain
8. Are there any stains on your teeth that bother you? Yes No Explain
9. Do you have old silver fillings you would like to have replaced with
tooth colored fillings? Yes No Explain
10. If you could change one thing about your smile or your teeth,
what would it be?