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

    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):

    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

    Tooth Movement

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

    Retention

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




    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

    Length of treatment

    1 = Not important, 10 = Very important

    Treatment fees

    1 = Not important, 10 = Very important

    Flexible finance options

    1 = Not important, 10 = Very important

    Use of latest technology

    1 = Not important, 10 = Very important

    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 virtual consultation?
      Invisible bracesTeeth WhiteningComposite BondingPorcelain VeneersReplace missing teeth
      2) How do you rate your smile?

      1 = Extremely unhappy, 10 = Extremely happy

      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):

      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

      Tooth Movement

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

      Retention

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




      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

      Length of treatment

      1 = Not important, 10 = Very important

      Treatment fees

      1 = Not important, 10 = Very important

      Flexible finance options

      1 = Not important, 10 = Very important

      Use of latest technology

      1 = Not important, 10 = Very important

      17) Upload your smile (optional)




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