6 9 LUMINEERSBY CERINATE SMILE EVALUATION 1A Simple Quiz to Help You Obtain the Smile Youve Always Wanted NO PAINYOU DONT EVEN NEED AN ASPIRIN 1THE MOST SIGNIFICANT COSMETIC ADVANCEMENT EVER Hold a m ID: 885064
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1 Health History /( Mr. Mrs. Miss Ms. ____
Health History /( Mr. Mrs. Miss Ms. _______ ___ _ ___________Birthdate______.Age___ Soc. Sec. No._ _ _ _ ___ _ _ _ Home address 6 9 LUMINEERS®BY CERINATE® SMILE EVALUATION A Simple Quiz to Help You Obtain the Smile You've Always Wanted NO PAIN-YOU DON'T EVEN NEED AN ASPIRIN. THE MOST SIGNIFICANT COSMETIC ADVANCEMENT EVER! Hold a mirror 12"-14" from your face. Smile to show your teeth. Take the time to observe your teeth carefully, then answer the following questions: Do you like the appearance of your teeth and your smile? 0 Yes No If not, explain _ ____________ _____ _ _ _ _ _
2 __ _ _ _ _ CALCIFICATION STAINS Are
__ _ _ _ _ CALCIFICATION STAINS Are your teeth... Chipped? 0 Yes 0 No Protruding 0 Yes 0 No Hidden 0 Yes 0 No If yes, explain __________ _______ _______ _ FANGED TEETH 7 Are your teeth wearing on the biting surfaces? 0 Yes 0 l'Jo If yes, explain _ ___________________ ____ _ 8 Are there old fillings or dental work you don't like looking at? 0 Yes 0 No STAINED AND CROOKED TEE TH If yes, explain _________________________ PORCElAIN CROWNS What would you like to change the most in the appearance of your teeth? 10 How would you like your teeth to look? L U E E R