Your Name

Date
January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , 2010 2011

1. Do you wish your teeth were whiter? Yes No

2. Do you love your smile? Yes No

3. Do you feel you show too many or too few teeth when you smile? Yes No

4. Do you wish you had longer or shorter teeth? Yes No

5. Would you prefer wider or narrower teeth? Yes No

6. Are your teeth too square or too round? Yes No

7. Do you like the way your teeth are shaped and positioned? Yes No

8. Are you satisfied with the way your gums look? Yes No

9. Do you think you show too much or too little gum tissue when you smile? Yes No

10. When you look at your smile in the mirror, do you see a minor defect in your gums or in one or more of your teeth? Yes No

11. Do you have any thoughts or comments regarding your smile? Yes No

If yes, please explain:

12. Would you like to discuss options to enhance your smile:

a. Now? Yes No
b. in 1-5 years? Yes No
c. in 5-10 years? Yes No

Your Email