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Smile Evaluation

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Smile Evaluation

First Name *

Last Name *

Date/Time *

Do you like the way your teeth look? *

Explain:

Are you happy with the color of your teeth? *

Explain:

Would you like for your teeth to be whiter? *

Explain:

Would you like your teeth to be straighter? *

Explain:

Do you have spaces between your teeth that you would like closed? *

Explain:

Would you like your teeth to be longer? *

Explain:

Do you like the shape of your teeth? *

Explain:

Do you have missing teeth that you would like to replace? *

Explain:

Do you have old silver fillings that you would like to replace with tooth-colored fillings? *

If you could change anything about your smile, what would you change? *

If you are a human seeing this field, please leave it empty.