Download You`ve been thinking about a healthier, more beautiful smile. Now

You’ve been thinking about a healthier, more beautiful smile. Now it’s time to discover if
Orthodontic Treatment is right for you and your lifestyle. You are about to make an investment
into your health and well-being for a lifetime. So, we’d like to get to know a little more about you
and your goals. By doing so, we may provide service beyond your expectations in our pursuit to
create a lifetime of beautiful smiles.
Please answer the following questions about your current smile, your daily habits and your
decision to pursue treatment with Kozak Orthodontics. We’ll compile your answers to better
assist you in this wonderful journey.
Q1. If you could change something about your smile, what would it be?
o Shape of Teeth
o Crowding/Overlapping of Teeth
o Color of Teeth
o Amount of Gum Tissue Showing
o Space In Between Teeth Closed
Q2. Please score the below items using the following scale.
1 = Most Important, 2 = Important, 3 = Somewhat Important, 4 = Neutral, 5 = Not Important
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
5
5
5
5
5
Straight Teeth
Perfect Smile
Facial Balance
Long-Term Stability and Health of Teeth/Bite
Healthy Chewing System
Q3. Please describe your profile in terms of Lip Position to us.
o Too Protrusive
o Just Right
o Too Retrusive
Q4. Please describe your profile in terms of Chin Position to us.
o Too Protrusive
o Just Right
o Too Retrustive
Q5. Please describe the Width of your smile.
o Too Wide
o Just Right
o Too Narrow
Q6. Please describe your Gum Levels of your smile.
o Too Gummy
o Just Right
o Not Enough Displayed
Q7. Describe your Tooth Brushing Habits.
o Perfect
o Needs Improvement
o My Gums Bleed When I Brush
Q8. Which of the following describes your concerns with your current smile, teeth and chewing
system? Please check all that apply.
o I show too much gum tissue when I smile.
o I have too much space in between my teeth
o My front teeth stick out too much.
o My lower teeth are ahead of my upper teeth so it’s difficult to bite into certain foods.
o My teeth are crooked or overlapping each other.
o The edges of my teeth are very flat and look worn down.
o I still have a baby tooth/teeth.
o I am missing teeth that would complete my smile.
o I have frequent headaches.
o My clench or grind my teeth.
o My jaw clicks or makes a popping sound when I open or close my mouth
Q9. What is your motivation for selecting Kozak Orthodontics as a source of information and
assistance to you on your beautiful smile journey? Please check all that apply.
o Location of Kozak Orthodontics
o Because I heard Dr. Kozak is not only concerned with a beautiful smile but also a healthy
chewing system to last my lifetime.
o My dentist said to come to you.
o My friend or family member referred me to you and they trust your opinion.
o My friends have braces and I want them too.
o You sponsored an event or organization that my child or I am involved in.
o I found you on the internet.
o Because I heard you have a fun office atmosphere.
o Because you offer a lifetime guarantee.
Q10. Please score the following responses that best describe key factors in your decision
making process.
1 = Most Important, 2 = Important, 3 = Somewhat Important, 4 = Neutral, 5 = Not Important
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
5
5
5
5
5
Quality of care
Treatment time or speed of treatment
Number of appointments necessary to complete treatment
Having clear braces or Invisalign as a treatment option
Ease of cleaning my teeth while in treatment
Q11. What types of interaction do you have with others on a daily basis?
o
o
o
I work in front of large groups of people such as public speaking or teaching.
I work on an individual basis in close proximity of others.
I do not regularly interact with others in person on a daily basis
Q12. All treatment options will require regularly scheduled appointments to allow treatment to
progress. Some appointments can be scheduled during a flexible time while others are not. How
flexible is your daily schedule to allow for appointments between the hours of 8:00 am and 5:00
pm?
o Very flexible, I manage my own schedule
o Somewhat flexible, depends on the day.
o Not very flexible. I have a hard time scheduling during the day time hours.
Q13. Which of the following is most important to you in choosing a treatment option for your
current smile?
o Low cost and flexible payment options
o Minimal impact on my personal life and career while I am going through treatment.
o A treatment plan that provides the least amount of discomfort without several limitations
on foods that I am able to eat.
o The quickest route possible to complete treatment.
Q14. How would you define a quality orthodontic result?
o
o
o
My teeth are straight
My teeth are straight, they look really nice and they fill my smile well
My teeth are straight, they look really nice, fill my smile and function well together
Q15. Are you an Adult or a Child?
o
o
Adult (18 years of age or older)
Child (17 years of age or younger)
Q16. When would you like to begin the journey towards a beautiful healthy smile?
o
o
o
Right now!
Within 6 months
Within 12 months
Q17. How would you like to be contacted with further information on your care and treatment?
o
o
o
Via Email
Via Phone Call
Via Mail
Q18. Contact Information:
o
o
o
o
Name:
Address:
Phone:
E-mail:
Thank you for allowing us to get to know you and your concerns. We look forward to discussing
your treatment needs in the near future at your initial consultation with our office. Congratulations
on taking the first step towards a beautiful healthy smile!