Smile Survey

Name *

Telephone *

Email *

Please tick Yes or No
1. Does the thought of seeing a dentist scare you?	YesNo
2. Are your teeth sensitive and uncomfortable when you eat?	YesNo
3. Do you notice blood in the sink when you spit whilst brushing?	YesNo
4. Are gaps appearing between your teeth with food trapping between them?	YesNo
5. Do you have chipped or worn teeth that you want repairing?	YesNo
6. Are you embarrassed about visiting a dentist because you feel you have neglected your teeth?	YesNo
7. Would you like a whiter smile?	YesNo
8. Would you like your teeth to be straighter?	YesNo
9. Are you fed up with loose dentures and want an alternative?	YesNo
10. Would you like to have smoother skin without anyone knowing you’ve used treatment?	YesNo
11. Are you concerned about the cost of your treatment?	YesNo

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