Smile Assessment

Step 1/4

Your Details

First Name

Last Name

Phone *

Email *

Step 2/4

Your Smile

Which teeth would you like to discuss?

Upper teeth

Lower teeth

Both

What are your main concerns with your smile? *

Toothache/pain

Chipped teeth

Gaps in the my teeth

Crooked teeth

Sticking out teeth

Dark tooth

Eroded/worn teeth

Discoloured teeth

Old dentures

Missing teeth

Gummy smile

Bleeding gums

Other

Choose all that apply.

Are there any particular treatments you are interested in? *

Cosmetic treatments

Orthodontics (Teeth straightening)

Dental implants (Replace missing teeth)

Endodontics (Root canal)

Periodontics (Gum health)

Other

Not sure

Choose all that apply.

Do you know when you would like to begin treatment? *

Immediately

Within the next 30 days

Within the next 6 months

Not sure, just would like more information

Step 3/4

Smile Photos

Please upload some photographs of your teeth to help our dentists assess your smile & advise on the best course of treatment.

Please note, below you can upload as many as five different photos. Take a look at the example image for some tips on taking the most helpful images. This is optional, but would be helpful.

Front Photo (1)

Lower Teeth Photo (2)

Upper Teeth Photo (3)

Right Photo (4)

Left Photo (5)

Step 4/4

Additional Info

Do you have a regular dentist? *

Yes

When was the last time you visited your regular dentist? *

Under 6 months ago

6-12 months ago

1-2 years ago

2+ years ago

I don't remember

I don't have a regular dentist

Do you have a regular hygienist/therapist? *

Yes

When was the last time you visited your regular hygienist/therapist? *

Under 6 months ago

6-12 months ago

1-2 years ago

2+ years ago

I don't remember

I don't have a regular hygienist/therapist

Do you have any health conditions or concerns that you think we should be aware of?

Is there anything you feel we didn’t ask you?

Would you like to arrange a consultation? *

Yes

Maybe later, for now I'm just looking for more information