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Online Consultation Form

On a scale of 1 – 10 how happy are you with your current smile? (1 is least happy, 10 is most happy)
Have you ever been to a Primo Dental Practice before?
Yes
No
When did you first notice the problem?
Within the last 6 months
Within the last 2 years
Within the last 5 years
Over 5 years ago
On a scale of 1-10 how much does it interfere with daily life? (1 is least interfering, 10 is most interfering)
How would you rate the current appearance of your teeth? (1 is worst, 10 is best)
Does this issue interfere with your sleep?
Yes - often
Yes - from time to time eg when stressed
Not sure
No - never
On a scale of 1-10 how nervous are you about visiting the dentist/ having treatment? (1 is least nervous, 10 is most nervous)
Is there any particular treatment that you are interested in?
How did you hear about us?
Bristol Dentist, Saltford dentist, Bath dentist

Exaggerated smile, back teeth biting together- from the left

1

Bristol Dentist, Saltford dentist, Bath dentist

Exaggerated smile, back teeth biting together- straight on to the camera

2

Bristol Dentist, Saltford dentist, Bath dentist

Exaggerated smile, back teeth biting together- from the right

3

Bristol Dentist, Saltford dentist, Bath dentist

Back teeth biting together moving lips away from teeth as much as possible

4

Bristol Dentist, Saltford dentist, Bath dentist

5

Teeth slightly apart so the as much of the upper and lower teeth can be seen. Moving lips away as much as possible

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