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Satisfied with your Smile? |
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Before your next dental exam, please print and complete our smile survey. Share your answers with your dental team and discover quick, affordable ways to get the smile you've always dreamed of.
Name: _____________________________________________
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| Do you wish your teeth were whiter? | 1 | 2 | 3 | 4 | 5 |
| Are your teeth stained? | 1 | 2 | 3 | 4 | 5 |
| Are your teeth crooked or overlapping? | 1 | 2 | 3 | 4 | 5 |
| Do you have broken, chipped or missing teeth? | 1 | 2 | 3 | 4 | 5 |
| Are you unhappy with the size or shape of your teeth? | 1 | 2 | 3 | 4 | 5 |
| Is your smile too "gummy"? | 1 | 2 | 3 | 4 | 5 |
| Do your fillings show when you smile? | 1 | 2 | 3 | 4 | 5 |
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