Cosmetic Dentistry Questionnaire Cosmetic Dentistry Questionnaire Name*FirstLastEmail*Enter EmailConfirm EmailPhone*Please contact me to discuss my responses by:*PhoneEmailAt appointment (only select if appt is scheduled)Best time to contact me:*MorningAfternoonEveningHow would you rate your smile?*It's awesome! I love it!I'm quite happy with with my smile but would consider some minor changesIt's OK (mild dissatisfaction)I'm unhappy with the appearance of my teethI'm embarrassed to smile or show my teethWould you prefer having brighter teeth?*YesNoIndifferentIn terms of teeth length, do you feel your teeth are:*Too longToo shortJust rightAre you happy with how much your teeth show when you smile?*Shows too muchDoes not show enoughJust rightWould you like to change the angle or orientation (slanted or rotated) of any teeth ?*YesNoDo you have any staining or mottling you'd like to have removed?*YesNoHow do you feel about the amount of gum tissue that shows when you smile?*Too muchNot enoughJust rightDo you think the gum tissue around your teeth is symmetrical?*Gum tissue seems higher over some teethGums seem symmetricalDo you have any dark crown margins that are visible?*YesNoDo you have purple or inflamed gums around a crown or filling?*YesNoAre you concerned about wear or chipping on your front teeth?*Very concernedModerately concernedNot really concernedDo you have any dark spaces, or triangles, between your front teeth?*YesNoAre you self-conscious about visible dark metal fillings when you smile?*YesNoWould you like to schedule a smile evaluation?*YesNoIf you could could make any changes to your smile, what changes would you make?Anything else you would like to discuss? Questions? We will be sure to address it when we follow up:CommentsThis field is for validation purposes and should be left unchanged.