The First Step On Your Smile Journey

Orthodontic Pre-Questionnaire

We are looking forward to meeting you very soon to discuss your smile. To help us understand your concerns, we hope you can spare a moment to return this questionnaire with as much detail as possible.

First Name

Last Name

What are you hoping to change with your current teeth?

Would you like the shape of your teeth changed? If so, which teeth specifically?

Do you have discoloured fillings you would like changed? If so, which fillings specifically?

Is there anything you feel self-conscious about when you smile? If so, what specifically?

Are you wanting to straighten your teeth? If you select No, skip the Adjustments section and click Next.

Yes No

Straighten Front Teeth

Upper Lower

Straighten Back Teeth:

Upper Lower

Move Upper Teeth:

Forward Back

Move Lower Teeth:

Forward Back

Move the Midline of the Upper Teeth to the:

Left Right

Move the Midline of the Lower Teeth to the:

Left Right

Do you have bleeding gums?

Yes No

Do you have a lot of calculus/hard plaque?

Yes No

Do you snore?

Yes No

Can you comfortably breathe for 3 minutes through your nose?

Yes No

Have you had your tonsils removed?

Yes No

Can you swallow a few sips of water without moving your face?

Yes No

Have you had a sleep study done?

Yes No

Have you had orthodontics previously?

Braces Invisalign Plates None

Is so, how long ago was your previous orthodontic treatment?

Get In Touch With Us Today

Simply fill out the form below and a member from Smile Studio Newstead will be in touch shortly.

First Name

Last Name

Phone

Which best describes you?

What service are you enquiring about?

Message:

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Orthodontic Pre-Questionnaire

Are you ready to redefine your smile? Our team at Smile Studio are here to help you on your smile journey, whenever you are ready.

Cosmetic dentistry, designed around you.

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