Dr. Robert Kluss’s Free Teeth Whitening Smile Analysis in the Laguna Hills CA area.

*First name:

*Last name:

*Phone:

*Email:

*ZIP/Postal Code:

How many teeth show in your smile?

Are you happy with your smile?

Yes No

Describe the color of your teeth:

Are your teeth evenly colored?

Yes No

Are there any defects on your front teeth?

Yes No

Any fillings or crowns showing?

Yes No

Are your teeth crowded?

Yes No

Do you have spaces or gaps between your teeth?

Yes No

How many?

Do your gums show when you smile?

Yes No

Do you like the amount of gums that show when you smile?

Yes No

Further comments about your smile: