smile-assessment – Dental Clinic Quezon City | Dental Clinic Makati

smile assessment Questionnaire

NOTE: Kindly provide all required information below. Please expect e-mail or text message from us confirming your appointment schedule. If ever your preferred schedule is already taken, You will automatically be booked on the next available slot for your consideration.

Please check your patient status:

New Patient Existing Patient

Personal Information

Your smile case:

Which teeth would you want to fix?

Upper Teeth Lower Teeth Both

What are your main concerns about your smile?

Gaps in my teeth Crooked teeth Sticking out teeth Discolored tooth Worn-out teeth Defective dentures Missing teeth Gummy smile Bleeding gums

Are there any particular treatments you are interested in?

Braces Crowns Veneers Implants Teeth whitening' Wisdom tooth removal Gum treatment

Do you have any schedule in mind when to start your treatment?

As soon as possible Within the next 30 days When the next 60 days Undecided yet

Please upload some photos of your teeth to enable us to assess your smile and come up with the best course of treatment for you.

Is there anything you feel like telling us? Please feel free to write it down here.

I understand that by clicking submit I hereby give my consent to any of your representative to call me to further discuss my smile concerns.

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Success Message

Your appointment booking request has been successfully submitted. Expect an email or a text message from us shortly for your appointment confirmation

Book another appointment?

Yes