Smile Assessment

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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2

3

4

5

6

7

8

9

10

4. Do you suffer from any of the following:*

Sensitive teeth

Bad breath

Mouth ulcers

Yellow tongue

Painful teeth

Stained teeth

Crooked teeth

Gaps or spaces

Bleeding gums

Wobbly 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:*

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:

9. Please upload a selfie to show your dentist your smile:

simle

Your smiley face From front

simle

Your smile From left side

simle

Your smile From right side

RESULTS!

To receive your smile assessment results, along with a complimentary consultation with our treatment coordinator, please complete your details below:

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