Smile Evaluation - Midwest Orthodontics Center

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Survey

Complete our smile evaluation to find out how we can help design your perfect smile.

Please note that your information is saved on our server as you enter it.

Step 1 of 11

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Name*
Email*
Phone*
Preferred Office?

I am...*
- A Teen
- An Adult
- A Parent (looking for my child)

People with straight teeth are regarded as having higher levels of:*
- Select All
- Attractiveness
- Health
- Success
- Self Esteem
- Wealth

(True/False) "I would love to have the full confidence to smile and show full, strong and white teeth"
- TRUE
- FALSE

What is Your Primary Goal?**
- Fix an overbite
- Fix an underbite
- Fix a crossbite
- Fix a gap
- Fix a crowding issue
- Straighter teeth in general

What appliance were you hoping to get treated with?*
- Least expensive
- Invisalign
- Open to options

How URGENT is it for you to take care of this?*
- Immediately! As soon as possible...
- Later this week
- Next week
- In the next 30 days
- Not very urgent

What's kept you from getting your smile fixed?*
- Nothing! I am ready right now
- Been to other dentists and they were too expensive
- Haven't found an orthodontist I'm comfortable with

Insurance normally covers only a small portion of orthodontic treatment. The majority of costs will need to be paid out of pocket or through financing. Will you move forward with treatment?*
- Yes
- No

Ortho Treatment can be a significant financial investment. Please describe your financial investment needs to better help us assist you*
- I am paying in cash for full treatment
- I can pay a portion of treatment , but will need additional financing
- I cannot pay any of the treatment costs and will need full financing

Upon receiving your evaluation we will contact you to schedule a date and time for your consultation. Do you commit to showing for your appointment ?*
- Yes, I commit to showing up for my consultation on time.
- NO

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