Patient Name:
EMR No:
Date:
Department:
Alabama
Wyoming
1. On a scale of 1-10, how would you rate your smile?
Choose
1
2
3
4
5
6
7
8
9
10
2. What changes would you make to improve your smile?
Straight Teeth
Whiter Teeth
Replace Broken/Missing Teeth
3. How would you feel if you had your ideal smile?
4. Have you had Orthodontic (teeth straightening) treatment in the past?
Yes
No
5. Would you like to have treatment to improve your smile?
Yes
No
6. How soon would like you like to start treatment to improve your smile?
Immediately
1-3 Months
3-6 Months
6-12 Months
Submit
