SMILE
EVALUATION
QUIZ

If you could improve your smile in a permanent, painless way, would you?

If you answer yes to any of the following questions, call Dr. Goldsmith today at 357.4018 to schedule a consultation.

1 Do you like the appearance of your teeth? Yes No
2 Are your teeth all in alignment (straight)? Yes No
3 Do you have spaces? Yes No
4 Do you like the color of your teeth? Yes No
5 Do you wish your teeth were whiter? Yes No
6 Are your teeth chipped? Yes No
7 Are your teeth protruding? Yes No
8 Are your teeth hidden? Yes No
9 Are your teeth wearing on the biting surfaces? Yes No
10 Are there old crowns, bridges, or fillings you don't like looking at? Yes No
11 Would you like us to contact you?? (Please fill out the information below) Yes No

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