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“Every patient wants to feel "special" and you have treated me that way with what I know to be knowledgeable and exceptional care.” - Ann

Smile Evaluation

Let Our General Dentistry Team Evaluate that Beautiful Smile Today!

Wilton Dental Smile Evaluation

Is your smile everything you want it to be?

Take a few moments to fill in this short evaluation to discover if there are any areas where you would like to see aesthetic improvements.

We will get back to you with an evaluation on what we can do to help you improve your smile.

Name*

Address

City

State

Phone

Email*

Do you dislike the color of your teeth?
yesno

Do you have spaces between your teeth that bother you?
yesno

Do you have chips or uneven edges on your teeth?
yesno

Do you feel that your teeth are too long or too short?
yesno

Do you have dark fillings that show when you smile?
yesno

Do your gums show too much when you smile?
yesno

Are your teeth crowded or crooked?
yesno

Do you have existing crowns or dental work that you consider ugly?
yesno

Are you self-conscious of your teeth or your smile?
yesno

Has anyone (family member, friend, etc.) ever suggested that you should have something done with your teeth or smile?
yesno

Do you avoid smiling when you have your picture taken?
yesno

Would you like to improve your existing smile?
yesno

Do you wish you had a new smile?
yesno


What concerns do you have regarding dental treatment to improve your smile?
Fear of treatmentTime of treatment concernsNot understanding treatmentEmbarrassment

Feel free to call our office at any time to set up a complimentary consultation or arrange for a second opinion. Otherwise, we will be in contact with you shortly to review your evaluation.