Smile Assessment

Title

First Name

Surname

Gender

Date of Birth

Telephone Number

Email Address

Form completed by:

Patient

Parent

Guardian

If you are not the patient, please provide your full name below:

2. How did you hear about us?

Referred by dentist

Yes

Recommended by dentist

Yes

Recommended by friend/ family

Yes

Google/ website

Yes

Social media (Facebook etc)

Yes

Other

Yes

If other, please specify:

If we were recommended to you, please let us know by whom?

3. What are your main concerns with your smile?

I am self-conscious about my teeth when I smile

Yes

I avoid showing my teeth when I smile

Yes

I've had negative comments about my teeth

Yes

I've been teased/ bullied about my teeth

Yes

Wonky

Yes

Gappy

Yes

Crowded

Yes

Prominent/ sticking out

Yes

My bite is uncomfortable

Yes

My jaw joint hurts/ clicks

Yes

Other, please specify:

5. Any previous treatment

Have you had braces before?

Yes

If yes, please provide further details

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

Other treatments I’m interested in:

Do you have a specific deadline to be finished by?

Yes

If yes, please provide details

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.

Upload Photo 1

Upload Photo 2

Upload Photo 3

Upload Photo 4

Upload Photo 5

Please see the video below on how to take your photos:

8. Please let us know your communication preferences

I am happy to be contacted via telephone call regarding appointments or treatment

Yes

I am happy to be contacted via text or email regarding appointments or treatment

Yes

I am happy to be contacted via text or email regarding special offers and practice news

Yes

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.

Please tick to certify that you have read and understood all the above information and that all of your answers are true and accurate.

Acknowledged

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

18 Grange Road
Stourbridge
DY9 7LE

Telephone: 01384 984350
Email: info@justorthodontics.co.uk
Social:

OPENING HOURS
Monday	8:15am to 4:30pm
Tuesday	8:15am to 4:30pm
Wednesday	8:15am to 4:30pm
Thursday	8:15am to 4:30pm
Friday	8:15am to 2:00pm

Smile Assessment Form

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