If you are 18 years old or older, we would be pleased to provide you with a free smile analysis.
Please provide us with the following information and a member of our staff will contact you soon to schedule an appointment.
Full Name *
Zip Code *
Are you happy with your smile? * YesNoNot sure
How many teeth show in your smile?
Describe the color of your teeth Very whiteOff whiteYellowDark yellowGrey
Are your teeth evenly colored? YesNo
Are there any defects on your front teeth? YesNo
Any fillings or crowns showing? YesNo
Are your teeth crowded? YesNo
Do you have spaces or gaps between your teeth? Yes - just oneYes - a fewYes - manyNo
Do your gums show when you smile? YesNo
Do you like the amount of gums that show when you smile? YesNo
Further comments about your smile
1615 E Iron Ave
Salina, KS 67401
Monday: 7am - 4:30pm
Tuesday: 7am - 4:30pm
Wednesday: 7am - 3pm
Thursday: 7am - 4:30pm
Friday: 7am - 4:30pm