Confidential Dental Self Assessment FormPlease enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Mobile Phone Number *What would you like to discuss during your consultation? *Teeth StraighteningTeeth WhiteningReplace Missing or Failing TeethCosmetic Dental VeneersSame Day CAD-CAM CrownsTMD/TMJ IssuesFacial Aesthetic TreatmentsSedation ServicesSomething ElseFeel free to elaborate in confidence below if you wishHow do you rate your teeth or smile from 0 (very unhappy) to 10 (very happy)? Selected Value: 0 What bothers you about your teeth or smile? *Overcrowded (upper teeth)Overcrowded (lower teeth)Gaps (between upper teeth)Gaps (between lower teeth)Missing teethDiscoloured teethUgly or crooked teethChipped or broken teethPainful or sensitive teethPainful or sensitive jaw jointsPainful or sensitive jaw musclesUncomfortable or loose denturesFailing past dentistrySomething ElseFeel free to elaborate in confidence below if you wishDo you have trouble eating whatever you want? *NoSomewhatSevere problems eatingFeel free to elaborate in confidence below if you wishHow long have you been thinking about getting something done about your teeth or smile? *Less than 1 yearBetween 1 and 5 yearsMore than 5 yearsWhy do you want to do something about your teeth or smile now? *Upcoming special occasionThe situation is worseningMore time to do it now / working from homeBetter position financiallySomething elseFeel free to elaborate in confidence below if you wishHow confident are you smiling (e.g, in photos or during video calls)? Selected Value: 0 Does your smile or any concern about your teeth hold you back in social settings or when you meet new people? *NoSometimesYesFeel free to elaborate in confidence below if you wishDoes your smile affect your confidence? *NoSometimesYesFeel free to elaborate in confidence below if you wishIs having a nice smile important for your career? *YesNoWhat would your dream teeth or smile be like? *WhiterStraighterMore secureLess painfulSomething elseFeel free to elaborate in confidence below if you wishWhat is your realistic budget? Selected Value: £0 Submit
