Smile Survey

Would you like us to contact you? Yes No

Gender: Male Female

1. How would you rate your opinion / feelings about your own smile?

It's awesome! I love it!
I'm quite happy with my smile but would consider some minor changes
Indifferent
It's okay (mild dissatisfaction)
I'm unhappy with the appearance of my teeth
I'm embarrassed to smile or show my teeth

2. In your own words, if you could make any changes to your smile what changes would you make?

3.  Would you prefer having brighter teeth?

Yes
No
Indifferent

4. In terms of tooth length, do you feel your teeth are:

Too long
Too short
Just right

5.  Are you happy with how much your teeth show when you smile?

Shows too much
Doesn't show enough
Just right

6.  Would you like to change the angle or orientation of any teeth?  (i.e. tipped, rotated...)

Yes
No

7.  Do you have any staining or mottling that you would like to have removed?

Yes
No

8.  How do you feel about the amount of gum tissue that shows when you smile?

Too much
Not enough
Just right

9.  In your opinion, are the gum tissues around your front teeth symmetrical?

Gum tissue is higher over some teeth
Gums seem symmetrical

10.  Do you have any dark crown margins that are visible?

Yes
No

11.  Do you have purple, or inflamed gums around a crown or filling?

Yes
No

12.  Are you concerned with the amount of wear and chipping on your front teeth?

Yes, very concerned
Moderately concerned
Not really concerned

13.  Do you have any dark spaces / triangles between your front teeth?

Yes
No

14.  Are you self-conscious about visible dark metal fillings when you smile?

Yes
No

15.  Would you like to schedule a smile evaluation?

Yes
No

Please click the button below to submit your survey