New Patient Special
“Every patient wants to feel "special" and you have treated me that way with what I know to be knowledgeable and exceptional care. You are indeed one of a very, and all too rare, few talented perfectionist and dedicated doctors, with an oceanic depth of concern for each and every patient.” - Ann

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Smile Evaluation

Bethel Dental Smile Evaluation

Is your smile everything you want it to be?

Take a few moments to fill in this short evaluation to discover if there are any areas where you would like to see aesthetic improvements.

We will get back to you with an evaluation on what we can do to help you improve your smile.

Name*

Address

City

State

Phone

Email*

Do you dislike the color of your teeth?
 yes no

Do you have spaces between your teeth that bother you?
 yes no

Do you have chips or uneven edges on your teeth?
 yes no

Do you feel that your teeth are too long or too short?
 yes no

Do you have dark fillings that show when you smile?
 yes no

Do your gums show too much when you smile?
 yes no

Are your teeth crowded or crooked?
 yes no

Do you have existing crowns or dental work that you consider ugly?
 yes no

Are you self-conscious of your teeth or your smile?
 yes no

Has anyone (family member, friend, etc.) ever suggested that you should have something done with your teeth or smile?
 yes no

Do you avoid smiling when you have your picture taken?
 yes no

Would you like to improve your existing smile?
 yes no

Do you wish you had a new smile?
 yes no


What concerns do you have regarding dental treatment to improve your smile?
 Fear of treatment Time of treatment concerns Not understanding treatment Embarrassment

Please leave this field empty.

Feel free to call our office at any time to set up a complimentary consultation or arrange for a second opinion. Otherwise, we will be in contact with you shortly to review your evaluation.