Virtual Smile Consultation "*" indicates required fields Δ EmailThis field is for validation purposes and should be left unchanged.First Name*Last Name*Patient Age*Phone Number*Your Email* What is your immediate concern?*Please Answer Yes Or No To The Following: Bite And Jaw Joint1. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) Yes No 2. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?* Yes No 3. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?* Yes No 4. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed? Yes No 5. Are your teeth becoming more crooked, crowded, or overlapped? Yes No 6. Are your teeth developing spaces or becoming more loose? Yes No 7. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together? Yes No 8. Do you place your tongue between your teeth or close your teeth against your tongue?* Yes No 9. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? Yes No 10. Do you clench or grind your teeth together in the daytime or make them sore?* Yes No 11. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?* Yes No 12. Do you wear or have you ever worn a bite appliance?* Yes No Smile Characteristics13. Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?* Yes No 14. Have you ever whitened (bleached) your teeth?* Yes No 15. Have you felt uncomfortable or self conscious about the appearance of your teeth?* Yes No 16. Have you been disappointed with the appearance of previous dental work?* Yes No New Patients & Emergency Appointments Welcome Request Appointment702-307-7777
