Smile Assessment Form

Welcome to your online smile assessment with Stevens Dental. I'm Dr Jonny Stevens and my passion is helping my patients overcome hurdles and achieving their goals.

Instagram Name - Please put the exact Instagram name *

How did you land on the Stevensdental page? *

The questions below are designed to give me some background information on your smile.

Why do you want to change your smile? *

Why is now the right time to start your smile transformation journey? *

Do you brush twice daily? *

Yes

Have you previously completed any teeth whitening? *

Yes

Have you previously completed any teeth straightening? *

Yes

If “Yes”, please note down how many months/ years ago?

Have you previously had any cosmetic work? Ie Crowns, bridges, implants, veneers

What are you interested in learning about? (tick all that apply) *

Invisalign (teeth straightening for top and bottom) - From £3000

Whitening - From £350

Composite edge bonding - From £315 per tooth

Composite veneers - From £400 per tooth

Porcelain veneers - From £1050 per tooth

Not sure

What shape do you prefer?

Choose your ideal shape *

Smile 1 - Square

Smile 2 - Square/Round

Not sure

What colour do you prefer?

Choose your ideal colour *

Smile 1 - Natural White

Smile 2 - White

Smile 3 - Very White

Not sure

Would you be interested in finance options? *

0% Over 10 - 12 months

9.9% Over 2 - 4 years

No thanks

How soon are you wanting to get started? *

Immediately

1 - 3 months

3 - 6 months

6 - 12 months

Please copy the below photos - your photos must be exactly the same as the examples below

Picture 1 - Wide Smile

Please do your biggest smile possible

Say the letter “e”

Picture 2 - Smile with your top and bottom teeth

Picture 3 - Bite together and copy the photo

Please put your teeth together, tilt your head upwards and pull your lip down.

Picture 4 - Bite together and copy the photo

Please put your teeth together and pull your cheek.

Picture 5 - Bite together and copy the photo

Please put your teeth together and pull your cheek.

Would you like to receive communication from us in the form of a newsletter? The newsletter is not only a way of keeping an eye on any offers but you can also see some amazing smile makeovers! *

Yes

Please ensure all questions are answered before submitting this form.