Smile Design Questionnaire

Thank you for participating. Please fill in the fields below.
  • First Name*
    0
  • Last Name*
    1
  • Email*a valid email address
    2
  • Phone Number*
    3
  • Please indicate how you want to improve your smile.
    4
  • Food*you like
    I have crooked teeth.
    I have noticeable spaces between my teeth.
    I am missing one or more of my teeth.
    My teeth are discolored.
    I have some front teeth that have plastic fillings which have discolored.
    I have a narrow smile that stops at just the front six teeth.
    My teeth look worn/flat.
    My back teeth look gray/black, I think, because of silver-mercury fillings.
    I feel like I show too much gum when I smile.
    My gums are not pink, but rather, red and puffy.
    I don't feel my smile matches the rest of my image.
    I am self-conscious about my smile.
    Other people have commented negatively about my smile,
    I find myself not smiling in photos,
    I cover my teeth with my hand or lips when smiling.
    5
  • Additional Information About You*
    6
  • 7