Smile Assessment Form

Due to the COVID-19 pandemic, the safety of our team and our valued patients is our main priority. In addition to our increased infection control procedures, we have therefore also had to introduce some new ways of working - one of which is asking all of our patients to complete the below Smile Assessment Form. Once we have received this, a member of our team will be in touch to organise your Free Consultation with us.

Thank you in advance for your co-operation on this, and for taking the time to help us keep everyone protected. We look forward to seeing you soon!

1. Patient Details


2. How did you hear about us?


3. What are your main concerns with your smile?



5. Any previous treatment

6. Are there any particular treatments that you are interested in?


7. Photos of your teeth

Please upload some photographs of your teeth to help our team assess your smile and advise on your best course of treatment. You may upload as many as five different photos, we would ideally like to see the front, left-side, right-side and top and bottom of your smile.




8. Please let us know your communication preferences
What we do with your data

GDPR guidelines require us to ensure that we keep your personal data safe and handle it responsibly. Here at Just Orthodontics we take these guidelines very seriously and have strict policies in place for this. We only keep information that is directly relevant to you and to your care. All data is stored securely in a digital format. We keep treatment records indefinitely - as you, or we, may need to refer back to them in the future. You are entitled to request copies of the records we hold about you and your treatment. You are also entitled to request that we make corrections to any errors in the data that we hold about you.


9. Sign off

By clicking 'send' you are consenting to us replying, and storing your details. (see our privacy policy).

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