Welcome to OptiSmile! We'd like to get to know you a little better
OptiSmile's main goal is to assist you to achieve optimal oral health and empower you to smile with confidence.  
This form should only take 5 minutes. Our website is secure and your information held in strict confidence.
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Email *
Name *
Surname *
Male or Female *
Title *
Cell phone number *
Address: number, street, apartment number *
Address: Suburb *
Address: City *
Address: Postal Code *
Address: Province *
Birthdate *
MM
/
DD
/
YYYY
What's your biggest challenge/problem when it comes to your teeth and oral health? *
How would it feel if OptiSmile helped you to solve this challenge/problem? *
What is your general goal for your oral health? What do you want long term? *
What is your specific oral health goal right now? What do you feel is important to start with this year? *
What dental care have you already tried? What frustrations did you have? What can OptiSmile do to help? *
Who was your previous dentist? When was the last time you had an x-ray, treatment or exam? How did it go? *
Rate your oral health now *
terrible
perfect
How healthy would you like your mouth to be? *
OK
perfect
How nervous are you at the thought of coming to the dentist? *
relaxed
scared
Are you able to smile with confidence? *
no
yes
How white are your teeth? *
yellow
white
How clean or stained are your teeth? *
Lot of tartar and stain
Very clean
How straight are your teeth? *
crooked
perfect
Do you have any of the following? please check the boxes
Which of the following are most  important to you, when making your dental health decision?  Please select 3-6 answers *
Required
Who is your medical doctor? Name and Phone number
Please list ANY medication you have taken in the last 6 months? *
Please list ANY health conditions that have affected you in the last 12 months, including operations, diseases, chronic conditions, allergies, high blood pressure, cancer......ANYTHING AT ALL ! (thank you :) *
I have read the above question, and  I hereby confirm that I DO NOT have any chronic or acute medical conditions listed above or other unlisted conditions or diseases. I will inform my treating dentist if anything changes in the future. (please type your name to sign below) *
Who is your closest relative/ friend? Name and Phone number *
We do not send invoices/statements to medical aids, but we can help you claim by adding your information to your invoices/payments so you can claim back after you have settled your account.  My Medical Aid Plan NAME and Member ID NUMBER is below:
Our dental practice software likes us to have a nice photo of you on the appointment book.  (best selfie or driver's license OK) Please email to reception@optismile.co.za  or WhatsApp to 071 140 0396 *
What made you decide to choose OptiSmile as your new dental home? How did you hear about us? Please check all that apply *
Required
Who is the happy OptiSmile patient that referred you?
What is your occupation? *
Is there anyone else you can think of that may need a new dentist? Kids, spouse, ageing parent, work colleague?
Please tick below
Signature (type name) *
Congratulations! These answers will assist us to help you achieve optimal oral health and empower you to smile with confidence.
Please make sure if you get a security reCAPTCHA that you find all the traffic lights,trucks,bridges or whatever they ask for otherwise, it won't submit. If you have submitted successfully you will see a message from Google Forms shortly after it goes through.
Respondent's Email Address *
A copy of your responses will be emailed to the address you provided.
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