Lancashire Smiles - Smile Assessment Form

First Name *

Last Name *

Phone *

Email *

What would you like to improve about your smile? *

To What extent do you agree or disagree with this statement:

I smile without showing my teeth or cover my mouth when smiling. *

Have you seen a dentist and hygienist in the last 6 months? *

Yes

No

Which package would you be considering? *

Teeth Whitening

Composite Bonding + Whitening

Invisalign Package including Whitening

Invisalign Package + Composite Bonding

Would you be interested in a payment plan with 0% interest to cover the cost of your new smile?

Yes

No

Maybe

Do you have a time-frame in mind to complete your smile makeover? *

2 Months

Under 9-months

Time is not an issue

Pictures

Please take these 3 pictures to help us access your smile. Tips for taking good pictures:

1. Use a smartphone
2. Have a friend take your photos (Selfies can work as well)
3. Use a flash or have good lighting
4. Capture your mouth only

Upload Picture 1 *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Upload Picture 2 *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Upload Picture 3 *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Is there anything else you would like to tell us?

Please answer all the required* questions before submitting this form.