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 Email 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 I agree to be contacted by Thorpe Dental Group via email/phone/text as outlined in the Privacy Policy. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Send Can we help you?Give us a call or drop us a line today