913 Boot Road
West Chester, PA 19380
(610) 701-0102 		General Dentistry, Family Dentistry, Cosmetic Dentistry, Laser Dentistry 3844 Kennett Pike
Greenville, DE 19807
(302) 575-0100

Cosmetic & Oral Hygiene Survey
Chances are you picked up this survey because you want to improve your smile. At one time there were limited means to enhance the appearance of your teeth. Today, however, there are a number of cosmetic treatments that can be performed in the dental office in just a few appointments.

To help you determine how you feel about your smile, take a moment to answer the following questions. Take your time, and answer each question as clearly and accurately as you can. This will help us make a definitive diagnosis and determine the type of treatment most suited to your needs.


1- Are you pleased with the general appearance of your teeth and smile?
If not, explain
Yes
Yes		 No
No
2- Are your teeth straight?
If not, explain
Yes
Yes		 No
No
3- Are there spaces between your front teeth that you dislike?
If yes, describe
Yes
Yes		 No
No
4- Are you satisfied with the color of your teeth?
If not, explain
Yes
Yes		 No
No
5- Are you satisfied with the shape of your teeth?
If not, explain
Yes
Yes		 No
No
6- Are any of your teeth: Chipped?   Protruding?   Hidden?
If yes, describe
Yes
Yes		 No
No
7- Are you satisfied with the way your teeth come together?
If not, explain
Yes
Yes		 No
No
8- Do you have old fillings or dental work that makes you less confident about your smile and/or appearance?
If yes, explain
Yes
Yes		 No
No
 
9- What would you most like to change about the appearance of your teeth?
10- How would you like your teeth to look to maximize your smile?

If you have questions in regard to this cosmetic survey, please feel free to inquire.