Keri Do, DDS - Smile Analysis

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How A Virtual Consult Works:

1) Let us know the treatment you are interested in along with your questions and concerns.

2) Send us a selfie of your smile and/or teeth HERE

2) Fill out the questionnaire below.

3) We will send you a customized response addressing your questions, concerns, and recommendations.

4) After reviewing our response, you can schedule an in-person visit with us.

	Are any of your teeth yellow, stained or somewhat discolored?		Yes No
	Would you like your teeth to be whiter?		Yes No
	Do you have any gaps or spaces between your teeth?		Yes No
	Are you missing any teeth?		Yes No
	Do you see any pitting or defects on the surfaces of your teeth?		Yes No
	Are the edges of any teeth worn down, chipped or uneven?		Yes No
	Do any of your teeth appear too small, short, large or long?		Yes No
	Do you have a "gummy" smile (too much of your gums show when smiling)?		Yes No
	Are your gums red, sore, puffy, bleeding or receded?		Yes No
	Do you have problem with sleep or snoring?		Yes No
	Are any of your teeth turned, crooked, or uneven?		Yes No
	Have you had previous orthodontic treatment or braces?		Yes No
	Does your jaw pop,lock, click or make noises?		Yes No
	Do you have headaches, migraines, or facial pain?		Yes No
	Do you have any crowns or bridges that appear dark at the edge of your gums?		Yes No
	Would you like to change anything about the appearance of your teeth or smile?		Yes No

For In-Office Consultation please call (808)988-6919 or contact us

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.