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Do You
Know Your S.A.S. number?
Your
Smile Assessment Survey:
How many Yes’s will you have?
and how many NO's?
1. Are
you happy with your SMILE?
Yes____ No____
If you
answered YES, you can discontinue this survey.
2. Are
you happy with the color of your teeth?
Yes____ No____
3. Are
you happy with the appearance of your teeth?
Yes____ No____
4. Are
you happy with the spacing of your teeth?
Yes____ No____
5. Do you
like to SMILE?
Yes____ No____
6. Do you
notice other people's teeth?
Yes____ No____
7. Are
your teeth straight?
Yes____ No____
8. If you
could change one thing about your SMILE what would you like to
change?
Turn in
your results to your dentist for a FREE no-obligation
SMILE
Assessment or print it out, fill it in and fax it to him at one of the
numbers below. Be sure to include your name and phone number in the area
below.
________________________
Name
________________________
Phone Number
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