Take some time to judge your smile with the list below. You should use a mirror and light to make it easier. You can bring the evaluation to your cosmetic consultation. Please check off your concerns: Spaces between teeth.......................... Discolored/old crowns.......................... Fillings/crowns that don't match.......... Missing teeth...................................... Silver fillings....................................... Broken fillings...................................... My teeth are: Too.long................. Discolored Too short................ Chipped Too wide............ Fractured/broken Too narrow.......... Crooked Crowded............................................ How would you rate your teeth and smile? What changes would you make to create a smile you've always wanted? Name:... Address:... City:... ..State:.. Phone:... Email:... How did you hear about us?:...