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Smile Analysis

Smile Analysis

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Name *

Phone *

Email *

Where are you from? *

What is your age? *

Under 13 13-18 19-25 26-35 36-50 Over 50 Prefer not to say

Would you like your teeth to be whiter? *

Yes No

Are you missing any teeth? *

Yes No

Are your teeth yellow, stained, or discolored? *

Yes No

Do you have any crowns or bridges that appear dark at the edge of your gums? *

Yes No

Do you have any crowns or bridges that appear dark at the edge of your gums? *

Yes No

Do you have a "gummy" smile (too much of your gums show when smiling)? *

Yes No

Does the appearance of your smile inhibit you from laughing or smiling? *

Yes No

When being photographed, do you smile with your lips closed instead of flashing a full smile? *

Yes No

Would you like to change anything about the appearance of your teeth or smile? *

Yes No

Do you have any gaps or spaces between your teeth? *

Yes No

Are any of your teeth turned, crooked, or uneven? *

Yes No

Do you see any pitting or defects on the surfaces of your teeth? *

Yes No

Do any of your teeth appear too small, short, large or long? *

Yes No

Do you have any gray, black or silver (mercury) fillings in your teeth? *

Yes No

Are the edges of any teeth worn down, chipped or uneven? *

Yes No

Do you have any prior dental work that appears unnatural? *

Yes No

Are your gums red, sore, puffy, bleeding or receded? *

Yes No

Are you self-conscious about your teeth or smile? *

Yes No

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Fill out the form below and one of our specialists will contact you.

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Upload Your Smile (Cell Phone Picture) *

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+1 (829) 343-5145

+1 (829) 343-5145

+1 (829) 343-5145

service@puntacanaoralhealth.com

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