Dr. James Brother’s Free Pediatric Dentist Smile Analysis in the Los Angeles 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:

I consent to receive SMS text messages from James Brother LLC6. Msg & data rates may apply.
Reply STOP to opt out. For HELP call our office at (213) 234-9876

Smile Analysis Questionnaire

Call for an appointment:
(213) 234-9876

Dr. James Brother

Smile Analysis Questionnaire

Call for an appointment:(213) 234-9876

Dr. James Brother

Call for an appointment:
(213) 234-9876