Do you have concerns about? (please check all that apply)

	Gaps or Spaces between Teeth
	Color of Teeth
	Shape of Teeth
	Size of Teeth
	Show too much Gum
	Symmetry of Teeth
	Position of Teeth (crooked or crowded)
	Teeth Chipped or Broken
	Discolored Restorations (i.e. existing crowns, fillings, bonding)
	Front Teeth
	Back Teeth
	Inflamed or Bleeding Gums

What do you like best about your smile?

What do you like least about your smile?

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