Analyze Your Smile

Please take a minute to rate your smile with the following checklist.

This will allow us to get an idea of what cosmetic solutions will be the best for you.

                                            

Name:
Phone #:
Email:

1. Could your smile be whiter?
YES_NO
2. Do you have excess space between your front teeth?
YES_NO
3. Do you have broken, chipped or worn teeth?
YES_NO
4. Do you have discolored fillings on your front teeth?
YES_NO
5. Do you have a “Gummy” Smile?
YES_NO
6. Are your teeth straight?
YES_NO
7. Are you satisfied with the shape of your teeth?
YES_NO

What would you most like to change about the appearance of your teeth?

You deserve the best the world has to offer, and a bright, beautiful smile is within your reach. Thank You.

Copy, Paste and e-mail to fleurdelisdental@gmail.com