Smile Analysis

Are your teeth stained or discolored?
YesNo

Would you love a whiter smile?
YesNo

Do you have any gaps or spaces in your smile?
YesNo

Are any of your teeth crooked or uneven?
YesNo

Do you have any missing teeth?
YesNo

Do you have any chips in your teeth?
YesNo

Do you have any misshapen teeth?
YesNo

Have your crowns or bridges created a dark edge near your gums?
YesNo

Do you have any gray, black or silver fillings you’d like to change?
YesNo

When you smile, do your gums show?
YesNo

Do your gums ever get red, sore, puffy, or bleed?
YesNo

Does the appearance of your smile stop you from smiling?
YesNo

Are you ready to change your smile at Valley Alder Family Dentistry?
YesNo