Smile Questionnaire – Thorpe Dental Group, York

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BISHOPTHORPE: 01904 703427

WOODTHORPE: 01904 706795

COPMANTHORPE: 01904 706291

ABOUT
IMPLANTS
- TEETH-IN-A-DAY
TREATMENTS
AESTHETICS
FAQS
CONTACT

BOOK NOW

ABOUT
IMPLANTS
- TEETH-IN-A-DAY
TREATMENTS
AESTHETICS
FAQS
CONTACT

Oral Health & Smile Questionnaire

Please complete the questionnaire before your appointment. All fields are required.
Do not use the BACK button while completing the form as you may lose your answers.

First name

Last name

Date of birth

Telephone

How happy are you with your smile?

Very unhappy Unhappy Neutral Happy Very happy

Would you like to improve anything about your smile?

Yes No

Select all that apply:

Position/alignment Shape Chips/damage Colour Fillings/dental work Gaps Symmetry Missing teeth

Are you aware of the treatments that we offer at Thorpe Dental Group?

Yes No

What does your oral hygiene routine include? (select all that apply)

Electric Toothbrush Manual Toothbrush Floss Tepe Brushes

Do you clench or grind your teeth?

Yes No

Would you like the dentist to discuss the options available to improve your smile?

Yes No

Would you be happy for our Treatment Coordinator to contact to you discuss this?

Yes No

How would you prefer us to contact you?

Email Telephone

Acceptance

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