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Smile Assessment Tool
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Creating beautiful smiles
Find out how you can achieve a beautiful smile with our
Smile Assessment Tool...
1. Are you...
*
Male
Female
2. Please select your age range:
*
18-24
25-34
35-44
45-54
55-64
65+
3. How would you rate your smile?
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1
2
3
4
5
6
7
8
9
10
4. Do you suffer from any of the following:
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Sensitive teeth
Bad breath
Mouth ulcers
Yellow tongue
Painful teeth
Stained teeth
Crooked teeth
Gaps or spaces
Bleeding gums
Wobbly teeth
Dark or discoloured teeth
5. Do you have any other concerns? Please describe below:
6. What is your reason for wanting to improve your smile?
*
For improved self confidence
I would like to eat with more ease
For my career reasons
For a special event
Another
If other please specify:
7. What don't you like about your teeth?
*
8. The treatment I am interested in is:
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Whiter teeth
Repair chipped teeth
Close spaces and gaps
Replace old dental treatment
Tooth coloured fillings
Straighter teeth
Replace missing teeth
Stabilise my denture
Replace wobbly & loose teeth
Help with my eating
Remove stains
Treat bleeding gums
Another reason
If other, please specify:
8. Please upload a selfie to show your dentist your smile:
Results!
To receive your smile assessment results, along with a complimentary consultation with our treatment coordinator, please complete your details below:
First name
*
Surname
*
Email
*
Telephone
*
