Copy 4 of Consultation Form5

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TMD/ Jaw Pain

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Hudson Valley TMD & Facial Aesthetics

2789 West Main St

Wappingers Fallas, NY 12590

845-836-3303

Consultation Form

Esthetic Self-Assessment

We are committed to creating beautiful smiles.

As I look at my teeth and smile in a mirror:

I wish my teeth were lighter in color.

I wish my teeth were straighter.

I wish the shape of my teeth was more attractive.

I wish my overall smile was more attractive.

I wish my teeth matched each other better.

I'd like a Smile Analysis and feedback

On a scale of 1-10 I'd rate my smile:

1

2

3

4

5

6

7

8

9

10

Signature of patients or guardian

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