Catalog excerpts
Smile Evaluation A Simple Evaluation to Help You Obtain the Smile You’ve Always Wanted Hold a mirror 12"–14" from your face. Smile to show your teeth. Take the time to observe your teeth carefully, and then answer the following questions: 1 Do you like the appearance of your teeth and your smile? □Yes □ No If not, explain ______________________________________________ _________________________________________________________ Are your teeth all in alignment (straight)? □ Yes □ No If not, explain ______________________________________________ _________________________________________________________ Do you have spaces that you don’t like? □ Yes □ No If yes, explain ______________________________________________ _________________________________________________________ Do you like the color of your teeth? □ Yes □ No If not, explain ______________________________________________ _________________________________________________________ Do you like the shape of your teeth? □ Yes □ No If not, explain ______________________________________________ _________________________________________________________ Are your teeth… Chipped □ Yes □ No Protruding □ Yes □ No Hidden □ Yes □ No If yes, explain ______________________________________________ _________________________________________________________ Are your teeth wearing on the biting surfaces? □ Yes □ No If yes, explain ______________________________________________ _________________________________________________________ Are there old fillings or dental work you don’t like looking at? □ Yes □ No If yes, explain ______________________________________________ _________________________________________________________ What would you like to change the most in the appearance of your teeth? _________________________________________________________ _________________________________________________________ How would you like your teeth to look? _________________________________________________________ _________________________________________________________ If you are not happy with the appearance of your teeth, ask your dentist how they can improve your smile.
Open the catalog to page 1Health History Mr. Mrs. Miss Ms. _____________________________________________________Birthdate_____________Age_______Soc. Sec. No._________________________ Home address__________________________________________________________City___________State__________Zip___________ Phone_____________________ Dental Insurance___________________________________________Group or Plan No.________________________Referred By________________________________ Person financially responsible___________________________________Relationship to you________________________ Soc. Sec. No._________________________...
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