Utica Dental - Leading provider of Invisalign and Lumineers

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Patient Name: Email Address: Phone Number: 1. List in priority the things you would most like to improve about your smile. 2. Have you had any previous esthetic dentistry? (If no, go to question #4) a. What was the reason for your previous work? b. When was your last dental visit? c. Who was your last Dentist? (name of doctor) 3. Do you have any interest in teeth whitening or orthodontics? 4. Do you have Dental Insurance? Please list your carriers, plan, etc. 5. Do you have an idea of your dental budget so that we may plan accordingly? 6. If you have not had another dental makeover, what are your realistic desires (i.e., what will/would it take for you to be satisfied with the outcome)? Think about this and be honest.