Yes No 1. Do you have any concerns about your smile?
Yes No 2. Do you cover your mouth with your hand when you smile or talk?
Yes No 3. Are some of your teeth darker than the others?
Yes No 4. Do some of your teeth have white or brown stains?
Yes No 5. Are you self-conscious about smiling in front of other people?
Yes No 6. Would you like a whiter, more youthful smile?
Yes No 7. Do you see any defects in the appearance of your teeth or gums?
Yes No 8. Are there spaces or gaps between any of your teeth?
Yes No 9. Are your teeth crowded?
Yes No 10. If you have crowding or spaces, is it getting worse?
Yes No 11. Are any of your teeth too long or too short?
Yes No 12. Are any of your teeth crooked, jagged, worn, or chipped
Yes No 13. Do you have old fillings or bonding that are chipped, discolored, misshaped, worn, or otherwise in need of upgrading?
Yes No 14. Do you have old veneers or crowns that need upgrading?
Yes No 15. Do you have missing teeth that you would like replaced?
Yes No 16. Is the appearance of your smile out of balance from one side to the other?
Yes No 17.Is there anything else about your teeth or your smile that you would like to change if it were possible?
If you answered “Yes” to any of these questions, you may want to discuss your options for cosmetic dentistry with us.