White Plains Dentist » Cosmetic Questionnaire Test Cosmetic Questionnaire Test Cosmetic Dentistry Questionnaire Cosmetic Dentistry QuestionnaireTake a brief questionnaire to explore the cosmetic conditions we treat and discover the financing options available to you. Startpress Enter Describe the condition of your teeth (select all that apply) * Chipped/broken Worn down Smaller than average Excessive gaps between teeth Discolored Are you generally happy with your smile? * Yes No Are your teeth as straight as you think they should be? * Yes No Are there gaps between your teeth that you don't like? * Yes No Are your teeth as white as you think they should be? * Yes No Do you like the shape of your teeth? * Yes No Are you aware of any teeth that are broken or chipped that require fixing? * Yes No It sounds like you love your smile and may not need cosmetic dentistry at this time. We can help you keep your beautiful smile healthy. Would you like to send your questionnaire answers to our office so we can help you maintain your smile? * Yes No Cosmetic dentistry treatments are generally not covered by insurance. However, affordable payment plan options exist. Are you interested in a payment plan option? * Yes, I'm interested in affordable payment plan options No, I will not need a payment plan How would you rate your credit? * Excellent Very Good Good Fair Poor Based on your responses, it sounds like you may be a great candidate for cosmetic dentistry! With his experience, skill, artistry, and attention to detail, Dr. Handschuh can help you obtain a smile you will be excited to share. Would you like to send your questionnaire answers to our office so we can help you improve your smile? * Yes No Based on your responses, it sounds like you may be a good candidate for cosmetic dentistry. If cosmetic dentistry is out of your reach right now, financially, we can certainly help you have a healthy smile in the meantime. Would you like to send your questionnaire answers to our office so we can help you with general and preventive dentistry? * Yes No Name * Email * Phone * Message What is the Best Way to Contact You? * PhoneTextEmail * By providing my wireless phone number and/or email, I agree and give consent to receive communication from The Dental Design Center via text message and/or email. Captcha Submit Thank you for taking our cosmetic questionnaire! If you have any questions about our cosmetic dental services, please contact us. If you are human, leave this field blank. ContinueSubmit Use Shift+Tab to go back
