Rate My Smile Questionnaire Please fill out and submit. We will be in touch within 2 business days to follow up with you! Contact info Patient Type*New PatientExisting Patient Please contact me by*PhoneEmail The best time to contact you*MorningAfternoonEvening Please rate your smile How 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 teeth If you could could make any changes to your smile, what changes would you make? Would you prefer having brighter teeth?* YesNoIndifferent In terms of teeth length, do you feel your teeth are:* Too longToo shortJust right Are you happy with how much your teeth show when you smile?* Shows too muchDoes not show enoughJust right Would you like to change the angle or orientation of any teeth? (slanted or rotated)* YesNo Do you have any staining or mottling you'd like to have removed?* YesNo How do you feel about the amount of gum tissue that shows when you smile?* Too muchNot enoughJust right Do you think the gum tissue around your teeth is symmetrical?* Gum tissue seems higher over some teethGums seem symmetrical Do you have any dark crown margins that are visible?* YesNo Do you have purple or inflamed gums around a crown or filling?* YesNo Are you concerned about wear or chipping on your front teeth?* Very concernedModerately concernedNot really concerned Do you have any dark spaces, or triangles, between your front teeth?* YesNo Are you self-conscious about visible dark metal fillings when you smile?* YesNo Would you like to schedule a smile evaluation?* YesNo How did you find Saby Dental? Internet SearchNewspaperRadioReferral from friends or familyOther
