Smile QuestionnaireFrom braces to porcelain veneers to complete smile makeovers – there are many techniques in cosmetic dentistry. Submit your answers then we will respond shortly with our recommendations. Name* First Last Email* Phone*Please contact me by:*EmailPhoneBest time to contact you:* Morning Afternoon Evening Rate your smile How would you rate your smile?*It's awesome! I love it!I'm quite happy with with my smile but would consider some minor changesIt's OK (mild dissatisfaction)I'm unhappy with the appearance of my teethI'm embarrassed to smile or show my teethIf you could could make any changes to your smile, what changes would you make?*Would you prefer having brighter teeth?* Yes No Indifferent In terms of teeth length, do you feel your teeth are:*Too longToo shortJust rightAre you happy with how much your teeth show when you smile?*Shows too muchDoes not show enoughJust rightWould you like to change the angle or orientation of any teeth? (slanted or rotated)*YesNoDo you have any staining or mottling you'd like to have removed?*YesNoHow do you feel about the amount of gum tissue that shows when you smile?*Too muchNot enoughJust rightDo you think the gum tissue around your teeth is symmetrical?*Gum tissue seems higher over some teethGums seem symmetricalDo you have any dark crown margins that are visible?*YesNoDo you have purple or inflamed gums around a crown or filling?*YesNoAre you concerned about wear or chipping on your front teeth?*Very concernedModerately concernedNot really concernedDo you have any dark spaces, or triangles, between your front teeth?*YesNoAre you self-conscious about visible dark metal fillings when you smile?*YesNoWould you like to schedule a smile evaluation?*YesNoComments or Questions*CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.