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  Name Date   Email Telephone

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