5000 Yonge Dental - Online Patient Forms

Aesthetic Questionnaire

Do you like your smile? Please fill out the following questionnaire to receive an aesthetic evaluation.

Your Full name:

Your Email Address:

1a. Do you like the way your teeth look?

Yes, If Yes, skip to Question 2
No

1b. If no: In relation to your lip line?

Yes
No

1c. When your lips are at rest?

Yes
No

1d. When you smile or speak?

Yes
No

2. Would you like more of your teeth to show?

Yes
No

3. Would you like less to show?

Yes
No

4a. Do you like the shade of your teeth?

Yes, If Yes, skip to Question 5.
No

4b. If no, Would you like them lighter?

Yes
No

4c. Would you like them brighter?
Yes
No

5. Are there fillings or other discolouration that are noticable?

Yes
No

6. Would like to reposition or straighten any of your teeth?

Yes
No

7a. Are your teeth getting shorter in length?

Yes
No, If No, skip to Question 8a.

7b. If yes, please select what you think is the cause(s):

day or night grinding
another habit
trauma or injury
poorly restored
other

If other, please specify:

8a. Do your teeth appear to be getting longer?

Yes
No,

If No, skip to Question 9a.

8b. If yes, please select what you think is the cause(s):

incorrect bite
periodontal
poor restoration
other

If other, please specify:

9a. Do you think your gums show too much?

Yes
No

If No, skip to Question 10

9b. If yes, please select when you think it occurs:

When you smile?
When you speak?
other

If other, please specify:

10. Are you aware that tooth reduction may be required in order to enhance your smile by prosthetic techniques?

Yes
No

PLEASE NOTE: AN AESTHETIC DENTAL EVALUATION DOES NOT REPLACE NOR INTEND TO UNDERMINE THE IMPORTANCE OF YOUR OVERALL GENERAL DENTAL HEALTH TREATMENT.

Toronto Dentist - Dental implants - Porcelain Crowns - Teeth Whitening - Porcelain Veneers

5000 Yonge Street - Main Floor, Suite 107 North York Toronto, Ontario M2N 7E9 t- 416 224 0677 f- 416 224 0691