Your name (mandatory)

Your email (mandatory)

Your phone number

Your date of birth
[date-789]

Do you smoke?
YesNo

Do you consume regularly ?
SodaCoffeeTeaWine

Do you have a disease that can affect the appearance of your teeth ?

Have you followed orthodontic treatment ?
OuiNon

If yes, When?

Do you think that your teeth are a matter of?
Of primary importanceVery importantImportant but not a major concern

Feeling

Are you embarrassed by the appearance of your teeth ?
YesNo

What would you change first of all in the appearance of your teeth ?

When you smile or laugh, you fear that the eyes of others is drawn to some aspect of your mouth ?
YesNo

Do you put your hand in front of your mouth when you smile?
YesNo

Aspect

Do you feel that your teeth are ?

Too shortToo longToo narrowToo wideToo roundToo squareNormal

Have you broken, damaged or missing teeth ?
YesNo

If yes, are they visible when you smile?
YesNo

Color

Do you find the color of your teeth ?

To whiteWhiteYellowGrayBrown

Do you have stains on your teeth?
YesNo

Alignment

Do you think that your teeth are aligned ?
YesNo

Do you have spaces between teeth ?
YesNo

Do you have an incomplete or missing tooth ?
YesNo

Restoration

Do you have fillings or crowns ?
YesNo

If yes, when you smile, do you see your fillings or crowns ?
YesNo

Smile

When you smile, do you find that your gums are ?
VisibleTo visibleNormal

Are you reluctant to smile ?
YesNo

Do you have a specific request or concern?

Are you reluctant to smile?
YesNo

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