Are any of your teeth yellow, stained, or somewhat discolored?

Yes

No

Would you like your teeth to be whiter?

Yes

No

Do you have any gaps or spaces between your teeth?

Yes

No

Are any of your teeth turned, crooked, or uneven?

Yes

No

Are you missing any teeth?

Yes

No

Do you see any pitting or defects on the surfaces of your teeth?

Yes

No

Are the edges of any teeth worn down, chipped, or uneven?

Yes

No

Do any of your teeth appear too small, short, large or long?

Yes

No

Do you have any prior dental work that appears unnatural?

Yes

No

Do you have any gray, black or silver (mercury) fillings in your teeth?

Yes

No

Do you have a "gummy" smile (too much of your gums show when smiling)?

Yes

No

Are your gums red, sore, puffy, bleeding or receded?

Yes

No

Does the appearance of your smile inhibit you from laughing or smiling?

Yes

No

When being photographed, do you smile with your lips closed instead of flashing a full smile?

Yes

No

Are you self-conscious about your teeth or smile?

Yes

No

Would you like to change anything about the appearance of your teeth or smile?

Yes

No

Did you answer YES to any of the questions above? There are often several alternatives to improve your teeth and smile. To receive a personalized response to your smile analysis, please complete the rest of the form below. You can have the smile you've always wanted!

Yes

No

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