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Overview New Patients Your Smile Caring for You Ask the Dentist
About You » Your Smile
We want to meet your needs and can help with all the following issues. Please √ any that concern you and hand this form to a member of the team.
I am self-conscious about my teeth when I smile. My gums bleed when I brush my teeth and I get a bad taste in my mouth.
My teeth are not as bright and white as I would like them to be. My teeth are sensitive.
I am unhappy about the colour of my crowns or fillings. My dentures feel uncomfortable.
Some of my teeth are dark, chipped or misshapen. I am worried about the cost of treatment and how to pay for it.
I have some missing teeth which affect my smile.  
On a scale of 1-10 (10 being best), I would rate my smile 
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