Name: _______________________________
How often do you have your teeth cleaned? ____________
How often do you brush your teeth? __________________
How often do you floss your teeth? ___________________
Do you grind or clench your teeth?
Do you bite your fingernails?
Do you chew on pens or pencils?
Do you smoke?
Do you drink coffee or hot tea?
If so, how many combined cups per day? ______________
Do you drink iced tea or colas?
If so, how many per day? ____________________
When you look in the mirror, do you like the appearance of your teeth?
Do you like the length of your teeth?
Do you like the shape of your teeth?
Do you have an stained teeth?
Do you like the color of your teeth?
Would you like your smile to look 10 years younger?
Do you have any spaces between your teeth?
Do you have any teeth with white spots?
Do you have any chips or cracks in your teeth?
Do you have any crooked teeth?
Are you missing any teeth?
If so, would you like to have the missing teeth replaced?
Do you have any silver fillings you'd eventually like replaced with tooth-colored ones?
Do you have any teeth you believe need caps or bonded porcelain inlays?
Do you have any caps that have metal showing through, or are unattractive to you?
Have you had braces in the past?
If yes, were you pleased with the results?
If yes, have you continued to wear your retainer, at least at nighttime?
Have you ever had or considered any cosmetic surgery?
Would you like to see what you would look like with a great smile?
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If you answered “Yes” to any of these questions
there’s good news - we can provide you with a more
beautiful smile. To learn more about our cosmetic
and therapeutic treatments available, simply click
here. Or, if you’re ready to take the next step,
please contact
us now!
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