Hold a face mirror 12" to 14" from your face. Smile to show your teeth; take the time to observe your teeth carefully. Fill out this form, or print it out and bring it with your appointment.
Name:
Email:
Do you like the appearance of your teeth; your smile? Yes No
If not, explain:
Are your teeth all in alignment (straight)? Yes No
If not, explain:
Do you have spaces that you don't like? Yes No
If yes, explain:
Do you like the color of your teeth? Yes No
If not, explain:
Do you like the shape of your teeth? Yes No
If not, explain:
Are your teeth chipped? Protruding? Hidden? Yes No
Are your teeth wearing on the biting surfaces? Yes No
If yes, explain:
Are there old fillings or dental work you don't like looking at? Yes No
If yes, explain:
What would you like to change the most in the appearance of your teeth?
How would you like your teeth to look?
