Brighter then White

Take advantage of our brighter than white smile promotion. For a limited time, Zoom Teeth Whitening is available in our office for only $550 (regularly $770). This fee includes all necessary appointments as well as all take- home kits.

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Please look into the mirror and evaluate your smile

Your name :
Your age :
Your e-mail address :

 

1. How many teeth do you show with your best smile?
2. My teeth seem too dark. YesNo
3.

How would you describe their color and shade?

very white moderate - white light - yellow
moderate - yellow dark - yellow light - brown
dark - brown moderate - grey dark grey
4.

How are color and shade distributed?

Even Uneven		  
5. Do you have white or discolored spots on your teeth? YesNo
6. Do you see any pitting or defects on the surface of your teeth? YesNo
7. Do your front teeth have any visible fillings and/or crowns? YesNo
8. Are your teeth crowded? YesNo
9. Do you have spaces between your teeth? How many? YesNo
10.

What shape and size do your teeth have? Please choose one value per section.

Section 1 Section 2 Section 3 Section 4 Section 5
Long Narrow Large Square Irregular
Short Wide Small Round Regular
Normal Normal Normal Tapered  
11. I see significant differences between neighboring teeth. YesNo
12. I show my gums when I smile. YesNo
13. I like the amount of gums that I show. YesNo
14.

How would you describe your lips?

Very Full Full Normal Narrow
15.

Is there anything you would like to mention about your smile? How did you find us?
16. I want to stay current on all latest advances in smile improvement technology, so please send me more information YesNo
   

Copyright © Aref El Natour, DDS, 2005