Tim Toohey Cosmetic Dentistry

Smile Survey

Many clients who wish to change the appearance of their teeth can clearly
identify and articulate their wishes. Others are able to recognize a few
elements of smile design but can't put their finger on exactly what doesn't
look right. The following is a list of questions that can help you identify
specific changes you may wish to make. Some of the most dramatic
smile makeovers we've completed have required only minimal treatment!

We hope you find this survey helpful!

First Name:
Last Name:	(optional)
Would you like us to contact you? Yes No
Email Address:	(optional)
Phone Number:	( ) (optional)
Please select age:
Gender:	Male Female

1. How would you rate your opinion / feelings about your own smile? It's awesome! I love it! I'm quite happy with my smile but would consider some minor changes Indifferent It's okay (mild dissatisfaction) I'm unhappy with the appearance of my teeth I'm embarrassed to smile or show my teeth
2. In your own words, if you could make any changes to your smile what changes would you make?
3. Would you prefer having brighter teeth? Yes No Indifferent
4. In terms of tooth length, do you feel your teeth are: Too long Too short Just right Comments:
5. Are you happy with how much your teeth show when you smile? Shows too much Doesn't show enough Just right
6. Would you like to change the angle or orientation of any teeth? (i.e. tipped, rotated...) Yes No Comments:
7. Do you have any staining or mottling that you would like to have removed? Yes No
8. How do you feel about the amount of gum tissue that shows when you smile? Too much Not enough Just right
9. In your opinion, are the gum tissues around your front teeth symmetrical? Gum tissue is higher over some teeth Gums seem symmetrical Comments:
10. Do you have any dark crown margins that are visible? Yes No
11. Do you have purple, or inflamed gums around around a crown or filling? Yes No
12. Are you concerned with the amount of wear and chipping on your front teeth? Yes, very concerned Moderately concerned Not really concerned
13. Do you have any dark spaces / triangles between your front teeth? Yes No
14. Are you self-conscious about visible dark metal fillings when you smile? Yes No
15. Would you like to schedule a smile evaluation? Yes No
Please click the button below to submit your survey

Your personal information will be used solely by Tim Toohey Cosmetic
Dentistry and will not be shared with any third party.

If you are unhappy with your smile, give us a call at 780-929-2929 to find out
about what we can do to give you a more beautiful smile !