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1.
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How many teeth do you show with your
best smile?
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2.
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My teeth seem too dark.
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Yes No
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3.
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How would you describe their color and shade?
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4.
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How are color and shade distributed?
Even Uneven
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5.
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Do you have white or discolored spots on your teeth?
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Yes No
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6.
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Do you see any pitting or defects on the surface
of your teeth?
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Yes No
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7.
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Do your front teeth have any visible fillings
and/or crowns?
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Yes No
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8.
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Are your teeth crowded?
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Yes No
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9.
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Do you have spaces between your teeth?
How many?
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Yes No
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10.
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What shape and size do your teeth have? Please choose one value per section.
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11.
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I see significant differences between
neighboring teeth.
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Yes No
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12.
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I show my gums when I smile.
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Yes No
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13.
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I like the amount of gums that I show.
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Yes No
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14.
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How would you describe your lips?
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15.
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Is there anything you would like to mention about your smile? How did you find us? Use the text area for your comments.
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16.
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I want to stay current on all latest advances in smile improvement technology, so please send me more information
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Yes No
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