Smile Assesment

Start Your Stress-Free Smile Consultation

Answer a few easy questions to learn more about what services are a good fit for you!

Are you a current patient?*

Yes, I am a current patient No, I am looking for a new dentist

When was the last time you went to the dentist?*

Within the last year More than a year ago

Since we are collecting health information, we will also need you to provide your last name.

First Name

Last Name

So, tell us: How often do you brush your teeth?*

A few times a week Once a day Twice a day More than twice a day

Daily oral hygiene is one of the biggest factors in oral health.

Do you floss?*

Yes, daily Sometimes Only if I have something stuck in my teeth Never

Regular flossing helps prevent gum disease and tooth decay.

What color best describes your smile?*

Super white Not as white as I would like, but not too yellow There's a significant yellow tint

Now, let's move on to your gums. | How would you describe them?*

Pink and firm to the touch Puffy and inflamed Red and receding

Do you have any oral concerns?*

Other

Phone Number

Email

By providing my wireless phone number and/or email, I agree and give consent to receive communication from Chisholm Creek Dental, via text message and/or email.

Smile Assesment

Start Your Stress-Free Smile Consultation

Answer a few easy questions to learn more about what services are a good fit for you!

Do you have a question?

Are you ready to schedule an appointment?

Office Hours

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