Heritage Oak Dental Clinic are here to help you achieve your dental goals. We want you to be informed of your dental needs so that you can make confident decisions concerning your dental health.
2841 109 St, Suite 201
Edmonton, Alberta
T6J6B7
Canada
info@edmontonfamilydentist.com
+1-800-125-6524/+1-587-600-2265
Mon : 8:00am - 5:00pm, Tue : 7:00am - 8:00pm, Wed, Thu, Fri: 7:00am - 2:00pm, Sat-Sun: Closed
780 434 9442 Toll Free 877 437 6288 Heritage Oak Dental Clinic, 2841 109 St, Suite 201, Edmonton, Alberta T6J 6B7
Open hours: Mon : 8:00am - 5:00pm, Tue : 7:00am - 8:00pm, Wed, Thu, Fri: 7:00am - 2:00pm, Sat-Sun: Closed

Your Smile Analysis

Name*

Phone*

Email*

ZIP/Postal Code

How many of your teeth show when you smile?

Are you happy with your smile?
 Yes No

What color are your teeth?
 very white off white yellow dark yellow grey

Are your teeth evenly colored?
 Yes No

Do your front teeth have defects?
 Yes No

Are you showing any crowns or fillings?
 Yes No

Are your teeth crowded?
 Yes No

Between your teeth do you have spaces or gaps?
 Yes No

If so, how many?

When you smile do your gums show?
 Yes No

Do you like how much your gums show when you smile?
 Yes No

Further comments about your smile