Call 020 8948 1040 | Whatsapp us | Email us | Find us Virtual Dentistry 20 Water Lane, Richmond, TW9 1TJ

Confidential Smile 

Evaluation Form 

    Some questions about how you feel about your smile…

    1) What would you like to talk about in your virtual consultation?
    Invisible bracesTeeth WhiteningComposite BondingPorcelain VeneersReplace missing teeth
    2) How do you rate your smile?

    1 = Extremely unhappy, 10 = Extremely happy

    5
    3) What is bothering you about your smile?
    Overcrowded: UpperOvercrowded: LowerGaps: UpperGaps: LowerSpaces: UpperSpaces: LowerTeeth stick outTeeth don’t show enoughNarrow smileTeeth at a slantTeeth at different heightsTeeth are different shapes
    4) Do you have difficulty eating what you want?
    NoSlightlyModeratelySevere problems eating
    5) How long have you been thinking about getting something done about your smile?
    Less than 1 year1-5 yearsMore than 5 years
    6) Why do you want to do something about your smile now?
    Special occasion coming upWorried about situation getting worseMore time to do it now/working from homeBetter position financially
    7) Rate how confident you are smiling in photos(or e.g. video calls):

    1 = Not important, 10 = Very important

    5
    8) Does your smile hold you back in social occasions, or when you meet new people?
    YesNoSometimes
    9) How does your smile affect your confidence?
    Not at allSlightlyModerate amountA lot
    10) Is having a nice smile important for your career?
    YesNo
    11) Are you happy with how white your teeth are?
    YesWant them naturally whiterWant them to be as white as they can be
    12) Are you happy with how wide your smile is?
    YesI want a slightly wider smileI want a much wider smile
    13) What would your dream smile look like?
    WhiterStraighterWider Smile
    14) What would you realistically be happy with?
    WhiterStraighterWider

    15) What is your understanding of the process of getting a new smile?

    Smile Design

    1 = I know nothing about the process, 10 = I know a lot about the process

    5
    Tooth Movement

    1 = I know nothing about the process, 10 = I know a lot about the process

    5
    Retention

    1 = I know nothing about the process, 10 = I know a lot about the process

    5

    16) How do you rate the following when choosing someone to improve your smile, and to look after your oral health?

    Experience and skill of the dentist

    1 = Not important, 10 = Very important

    5
    Length of treatment

    1 = Not important, 10 = Very important

    5
    Treatment fees

    1 = Not important, 10 = Very important

    5
    Flexible finance options

    1 = Not important, 10 = Very important

    5
    Use of latest technology

    1 = Not important, 10 = Very important

    5

    17) Upload your smile (optional)

    Confidential Smile 

    Evaluation Form 

      Some questions about how you feel about your smile…

      1) What would you like to talk about in your consultation?
      Invisible bracesTeeth WhiteningComposite BondingPorcelain VeneersReplace missing teeth
      2) How do you rate your smile?

      1 = Extremely unhappy, 10 = Extremely happy

      5
      3) What is bothering you about your smile?
      Overcrowded: UpperOvercrowded: LowerGaps: UpperGaps: LowerSpaces: UpperSpaces: LowerTeeth stick outTeeth don’t show enoughNarrow smileTeeth at a slantTeeth at different heightsTeeth are different shapes
      4) Do you have difficulty eating what you want?
      NoSlightlyModeratelySevere problems eating
      5) How long have you been thinking about getting something done about your smile?
      Less than 1 year1-5 yearsMore than 5 years
      6) Why do you want to do something about your smile now?
      Special occasion coming upWorried about situation getting worseMore time to do it now/working from homeBetter position financially
      7) Rate how confident you are smiling in photos(or e.g. video calls):

      1 = Not important, 10 = Very important

      5
      8) Does your smile hold you back in social occasions, or when you meet new people?
      YesNoSometimes
      9) How does your smile affect your confidence?
      Not at allSlightlyModerate amountA lot
      10) Is having a nice smile important for your career?
      YesNo
      11) Are you happy with how white your teeth are?
      YesWant them naturally whiterWant them to be as white as they can be
      12) Are you happy with how wide your smile is?
      YesI want a slightly wider smileI want a much wider smile
      13) What would your dream smile look like?
      WhiterStraighterWider Smile
      14) What would you realistically be happy with?
      WhiterStraighterWider

      15) What is your understanding of the process of getting a new smile?

      Smile Design

      1 = I know nothing about the process, 10 = I know a lot about the process

      5
      Tooth Movement

      1 = I know nothing about the process, 10 = I know a lot about the process

      5
      Retention

      1 = I know nothing about the process, 10 = I know a lot about the process

      5

      16) How do you rate the following when choosing someone to improve your smile, and to look after your oral health?

      Experience and skill of the dentist

      1 = Not important, 10 = Very important

      5
      Length of treatment

      1 = Not important, 10 = Very important

      5
      Treatment fees

      1 = Not important, 10 = Very important

      5
      Flexible finance options

      1 = Not important, 10 = Very important

      5
      Use of latest technology

      1 = Not important, 10 = Very important

      5

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