Smile Survey
Your Smile is the Easiest Way to Improve your appearance! Find out how your smile desires compare to others. Results will be shown at the end of the survey! As a thank you gift to you for taking our survey we would like to give you $100 towards your smile changing treatment at Grandview Dental Care This survey is intended to get a better understanding of your smile desires and dislikes. Hold a mirror 12" - 14" from your face. Smile to show your teeth. Take the time to observe your teeth carefully and then answer the following questions.
 
1.
Do you like the appearance of your teeth and your smile? If not, please comment below on what you would like to change.
Yes
No
  • Comment:

  • 500 character(s) left.
2.
Would you like your teeth to be straighter?
Yes
No
3.
Do you have spaces that you don't like? If yes, please comment below.
Yes
No
  • Comment:

  • 500 character(s) left.
4.
Do you like the color of your teeth?
Yes
No
  • Comment:

  • 500 character(s) left.
5.
Do you like the shape of your teeth. If not, please comment below.
Yes
No
  • Comment:

  • 500 character(s) left.
6.
Are your teeth...
chipped?
protruding?
hidden?
7.
Are your teeth wearing on the biting surfaces? If yes, please comment below.
Yes
No
  • Comment:

  • 500 character(s) left.
8.
Are there old fillings or dental work you don't like looking at? Please comment further.
Yes
No
  • Comment:

  • 500 character(s) left.
9.
What would you like to change the most in the appearance of your teeth?
 

  • 350 character(s) left.
10.
How would you like your teeth to look?
 

  • 350 character(s) left.
11.
What is holding you back from getting the smile of your dreams? Choose all the apply.
Time
Have not ever been asked what I would change about my smile
I'm afraid of the dentist
A nice smile is not that important to me
I chose to spend my money on other things
12.
If you are not happy with the appearance of your teeth we can help! We offer a complimentary Smile Consultation with the doctor. Fill out the information below and we will contact you to set up an appointment. Thank you for taking our survey. As our gift to you we would like to give you $100 towards your smile changing treatment at Grandview Dental Care. But, you have to tell us who you are, so that we can credit your account!
First Name:
Last Name:
Work Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code: