SMILE ASSESSMENT
Help us answer a few questions to better assist your smile!
Who is it for? (Select One)
*
My Child (7 - 11yr)
My Teenager (12 - 18yr)
Adult (18+)
I feel like my teeth are ____________.* (Please choose up to two option(s) below)
*
Overbite
Underbite
Crossbite
Crooked Teeth
Open Bite
Gap Teeth
Other
Your First Name
*
Last Name
*
Date of Birth
*
Phone Number
Your Email Address
*
What else do we need to know?
Do you have dental insurance?
If you are not sure, leave blank
Yes
Have you had braces before?
If you are not sure, leave blank
Yes
Treatment Preference
Ex. Braces, Invisalign, etc.
What would you like changed about your smile
Ex. Crowding, Spacing, etc.
Dentist
Preferred Office
Select Location
Howard Beach
Forest Hills
Signature
Date: