020 8460 9742

Smile Survey

Please have a look through the questions below and fill in as appropriate. You can either complete this form below or download a copy and print it off ready for your next visit. Your dentist will discuss any issues highlighted and will be pleased to help you achieve the smile you would like. We look forward to hearing from you.

Your Name*
Telephone*
Email*

1. Are any of your teeth stained or discoloured?*

Yes No

2. Are any of your teeth out of line?*

Yes No

3. Are any of your teeth damaged, misshapen or unsightly*

Yes No

4. Are any of your teeth visibly missing?*

Yes No

5. Do you have any dark fillings?*

Yes No

6. Do you have any stained or discoloured fillings?*

Yes No

7. Do you have any crowns with visible edges?*

Yes No

8. Would you like whiter and brighter teeth?*

Yes No

9. Are your gums pink and healthy?*

Yes No

10. Do your gums bleed when brushing, flossing?*

Yes No

11. On a scale of 1-10 (10 being best), how would you rate your smile?*

12. What would you change to your smile to make it a 10?

13. Are you interested in wrinkle correction treatment or softening facial lines?*

Yes No

14. Are you interested in lip enhancement treatment?*

Yes No

15. Would you like fresher breath?*

Yes No

16. Is there anything else regarding your smile and oral health that we can help you with?

17. Is finance an obstacle to having the healthy mouth and smile you would like?*

Yes No

Winter Smile Offers

Free hygienist treatment
with any full mouth
whitening
procedure

Wrinkle correction,
3 areas for the
price of 2

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Contact Us

Opening Hours: Mon/Wed/Fri 9am – 5.30pm Tue/Thu 9am – 8pm Saturday morning by appointment

Address: The Buckley Practice, 31 Tweedy Road, Bromley, Kent BR1 3PR