Are you delighted with your smile? Please rate your smile from 1 to 10 (1= I hate my smile, 10= awesome) Would you like to have whiter teeth? Yes No

If you had a magic wand what, if anything, would you change about your smile? What (if any) personal or professional benefit might you gain if you had a gorgeous smile? Do you have any special occasions coming up?

Through state of the art technology of Cosmetic Dentistry, we have the ability to help you achieve a World-Class Smile, often overnight. Using Computer Assisted Dental Imaging and High Resolution Video Photography, we can simulate very closely how YOU would look after the improvements, PRIOR to any treatment! Imaging can be performed as part of your exam visit (at NO additional charge). Would you like to see what YOU would look like with a new and improved smile? Yes No . If yes, please check off all that apply:

Please add anything you feel is important:

At Yardley Family Dentistry, though our focus is on appearance-related dentistry, we can deliver 99% of your routine dental needs as well. With flexible payment plans as well as phasing treatment over time, you and your family can achieve spectacular long-term results. Thank you so much for the opportunity to be of service.

Warm regards,

Jared S. Kenwood, DDS