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Pre-Appointment Questionnaire

We would like to understand what matters to you so we can tailor your treatment options. Please take a few minutes to complete this short questionnaire to help us with your pre-assessment.

Please refer to the examples below for guidance on how to take your photos.

You may need to use your fingers to gently move your lips aside to ensure your teeth are fully visible.

Front example

Right side example

Left side example

Lower teeth example

Upper teeth example

First name*

Last name*

Date of Birth*

Day

Month

Year

Email*

Which practice are you attending?*

What is the reason for your visit?*

How happy are you with your smile?*

Very happy

Fairly happy but there are things I'd like to change

Not very happy

I don't like my smile at all

Which of the following are of concern to you?*

Crooked / crowded (wonky) teeth

Gaps between teeth

Overlapping teeth

Misaligned bite

Teeth have moved since past orthodontic treatment

Chipped / worn teeth

Plaque build-up

Colour of teeth

Other

Have you noticed any of these issues?*

Teeth grinding or clenching

Jaw pain

Issues with chewing or speech

Difficulty keeping teeth clean

None of the above

Other

Is there anything else you would like to add?

Please upload your photos here*

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