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!

*All fields are required for a successful submission.

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 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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