Are your teeth stained or discolored? YesNo
Would you love a whiter smile? YesNo
Do you have any gaps or spaces in your smile? YesNo
Are any of your teeth crooked or uneven? YesNo
Do you have any missing teeth? YesNo
Do you have any chips in your teeth? YesNo
Do you have any misshapen teeth? YesNo
Have your crowns or bridges created a dark edge near your gums? YesNo
Do you have any gray, black or silver fillings you’d like to change? YesNo
When you smile, do your gums show? YesNo
Do your gums ever get red, sore, puffy, or bleed? YesNo
Does the appearance of your smile stop you from smiling? YesNo
Are you ready to change your smile at Valley Alder Family Dentistry? YesNo
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