*Patient Name:

*E-mail Address:

Phone Number:

1. List in priority the things you would
most like to improve about your smile.

2. Have you had any previous esthetic
dentistry? (If no, go to question #4)

a. What was the reason for your
previous work?

b. When was your last dental visit?

3. Do you have any interest in teeth
whitening?

4. If you have never had dental esthetic
work, what are your realistic desires -
i.e., what will/would it take for you to be
satisfied with the outcome?