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Deer Park: 281-479-5373
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New Smile Questionnaire
New Smile Questionnaire
Please use this questionnaire to help determine your feelings about your smile.
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Name
*
First
Last
Today's Date
What bothers you the most about your smile?
Are there any spaces that you do not like?
Yes
No
If yes, please explain:
Is there a need for more space?
Yes
No
If yes, please explain: (copy)
Is crowding a problem?
Yes
No
If yes, please explain:
Do you like the shape of your teeth?
Yes
No
If yes, please explain:
Do you like the way your bottom teeth and top teeth fit together?
Yes
No
If yes, please explain:
Do you have any discolored or old fillings that bother you or that you don't like seeing when you smile?
Yes
No
Are your teeth as bright as you would like?
Yes
No
How would you like your smile to look?
If yes, please explain: (copy)
Have anyone ever shown you what you'd look like if you changed your smile?
Yes
No
If yes, please explain: (copy)
Name
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We are dedicated to giving each of our patients the healthy smile they deserve!
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