Cosmetic Dentistry
Cosmetic Fillings
Crowns and Bridges
Specialty Dentures
Restores Implants
Lumineers Smile Evaluation
Dental Veneers
Teeth Whitening
Botox and Juvederm
Sedation Dentistry
Preventative Dentistry
Dental Problems
General Dentistry
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 Call: 770.382.5678
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Lumineers Smile Evaluation

A simple questionaire to help you get the smile you've always wanted
Hold a mirror 12-14 inches from your face. Smile to show your teeth. Look at your teeth very carefully, then answer the following questions. If you are not happy with the appearance of your teeth, ask your dentist how LUMINEERS can give you a beautiful, white smile.
1. Do you like the appearance of your teeth and smile?    Yes  No
If not, explain:  
2. Are your teeth all in alignment (straight)?    Yes  No
If not, explain:  
3. Do you have spaces that you don't like?    Yes  No
If yes, explain:  
4. Do you like the color of your teeth?    Yes  No
If not, explain:  
5. Do you like the shape of your teeth?    Yes  No
If not, explain:  
6. Are your teeth   chipped?  protruding?  hidden?
If not, explain:  
7. Are your teeth wearing down on the biting surfaces?    Yes  No
If yes, explain:  
8. Are there old fillings or dental work you don't like looking at?    Yes  No
If yes, explain:  
9. What would you like to change the most about the appearance of your teeth?  
10. How would you like your teeth to look?  
11. Would you like to see a photo of how your smile could look with LUMINEERS?    Yes  No
Your Name:  
Your Email:  


100 Courtyard Drive, Cartersville, GA  30120
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