Smile Evaluation

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At Ballard Dental Associates, we are committed to helping you discover and obtain the smile you have always wanted. Please take a moment to complete this questionnaire. This information helps us ensure we are serving you to the best of our ability.

Name:

Email Address:

1. Are you happy with the way your teeth look when you smile?:

2. Are you happy with the color of your teeth?:

3. Do you have any spaces between your teeth that you are unhappy with?:

4. Do you have any old fillings or treatment you are unhappy with?:

5. Is there anything you would change about your smile? What would it be?:

Ballard Dental Associates

Smile Evaluation

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