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Porcelain Veneers Form

    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:

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    Smile Evaluation

    A simple Evaluation to Help You Obtain the Smile You’ve Always Wanted

    Continue the smile evaluation:

    1. Do you like the appearance of your teeth and your smile?

    YesNo

    If not, explain

    2. Are your teeth in alignment (straight)?

    YesNo

    If not, explain

    3. Do you have spaces that you don’t like?

    YesNo

    If yes, explain

    4. Do you like the color of your teeth?

    YesNo

    If not, explain

    5. Do you like the shape of your teeth?

    YesNo

    If not, explain

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    Smile Evaluation

    Almost there – just a few more questions

    6. Are your teeth…

    Chipped YesNo

    Protruding YesNo

    Hidden YesNo

    If yes, explain

    7. Are your teeth wearing on the biting surfaces?

    YesNo

    If yes, explain

    8. Are there old fillings or dental work you don’t like looking at?

    YesNo

    If yes, explain

    9. What would you like to change the most in the appearance of your teeth?

    10. How would you like your teeth to look?

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