SMILE SURVEY
Please have a look through the questions below and fill in as appropriate. You can either complete this form below or download a copy and print it off ready for your next visit. Your dentist will discuss any issues highlighted and will be pleased to help you achieve the smile you would like. We look forward to hearing from you.
1. Are any of your teeth stained or discoloured?
2. Are any of your teeth out of line?
3. Are any of your teeth damaged, misshapen or unsightly?
4. Are any of your teeth visibly missing?
5. Do you have any dark fillings?
6. Do you have any stained or discoloured fillings?
7. Do you have any crowns with visible edges?
8. Would you like whiter and brighter teeth?
9. Are your gums pink and healthy?
10. Do your gums bleed when brushing, flossing?
11. On a scale of 1-10 (10 being best), how would you rate your smile?
12. What would you change to your smile to make it a 10?
13. Are you interested in wrinkle correction treatment or softening facial lines?
14. Are you interested in lip enhancement treatment?
15. Would you like fresher breath?
16. Is there anything else regarding your smile and oral health that we can help you with?
17. Is finance an obstacle to having the healthy mouth and smile you would like?
© 2017  The Buckley Practice
Registered Address: 1 Abacus House, Newlands Road, Corsham, Wiltshire SN13 0BH
Registered in England: 06048010
powered by cyberise