Let us reveal your perfect smile Answer the questions overleaf to let us know how our dental experts can provide you with the advice and care you need.
Your answers are for our records only and will be treated as confidential.
What, if anything, would you like to improve about your smile?
On a scale of 1-5, how happy are you with your smile? Very unhappy
1
2 3
4
5 Very happy
What would you change about your smile? Position /alignment of teeth
Shape
Chips /damage
Colour
Proportion
Fillings /dental work
Gaps
Symmetry
Replace missing teeth
When deciding to start a dental treatment, which of these factors would you consider? Price
How quickly treatment can start
Length of treatment
No need for brackets/buttons attached to my teeth
Comfort
Being able to see a picture of myself with the intended result
Aesthetics
Other (please specify):
Frequency of checkups Would you be interested in a treatment that would also whiten your teeth while they are being straightened? Yes
No
When would you like to reveal your new smile? Wedding
Holiday
Birthday
As soon as possible
What is the date of this event?
How soon would you like to start treatment? Immediately
Within 3 months
Within 1 month
3+ months
Is there anything else you’d like to add?
Please email back to us or hand in to reception. Thank you!
Other (please specify):