Cosmetic Dentistry Smile Assessment Form

Full Name Email Address Phone Number

Smile Concerns

Whiteness of teeth

Alignment/crooked teeth

Gaps between teeth

Chipped/Broken teeth

Teeth length or shape

Gummy smile

Other

Please describe your smile concerns

What would you like to improve about your smile?

Have you had any cosmetic dental treatments before?

Yes

If yes, please specify the treatments

What is your main goal or motivation for seeking cosmetic dental treatment?

How soon would you like to start your treatment?

Additional Questions or Comments