Lumineer Survery


Lumineer Smile Survey

Improve your self-image by having the smile that you want!

At Bright Smiles Dental, we strive to offer the very best in patient care. In order to provide the very best in care to you at your next visit, we need to know the things that you would change about your smile if you had the ability to do so.  The information below will be used to guide the dentists conversation at your next visit, and will only be used to facilitate a better smile.

How would you rate your smile according to the questions below? If a particular line does not apply to your visit, please skip it.

Yes No
1.   Do you like the appearance of your teeth?
6.   Are ALL your teeth in alignment (straight)?
7.   Do you have any spaces?
8.   Do you like the color of your teeth?
9.   Do you wish that your teeth were whiter?
10.   Are your teeth chipped or cracked?
11.   Are your teeth protruding?
12.   Are your teeth hidden?
13.   Are your teeth wearing on the biting surface?
14.   Are there old crowns, bridges, or fillings you don't like looking at?
Please provide us with your contact information so that we may contact you in order to assess you cosmetic dentistry needs. Once you email this form we will have it on hand at your next visit. Please use the boxes below:
  Phone Number:
  Email Address:


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