Patient Questionnaire

    Your smile affects your self-image, and can greatly influence the quality of your interactions with others. Many people hold back from laughing or smiling because they are uncomfortable with their smile. The following questions are designed to honestly appraise your smile. Go to a mirror, smile as wide as you can, and ask yourself the following questions:

    Are any of your teeth yellow, stained or somewhat discolored?

    Would you like your teeth to be whiter?

    Do you have any gaps or spaces between your teeth?

    Are any of your teeth turned, crooked, or uneven?

    Are you missing any teeth?

    Do you see any pitting or defects on the surfaces of your teeth?

    Are the edges of any teeth worn down, chipped or uneven?

    Do any of your teeth appear too small, short, large or long?

    Do you have any prior dental work that appears unnatural?

    Do you have any crowns or bridges that appear dark at the edge of your gums?

    Do you have any gray, black or silver (mercury) fillings in your teeth?

    Do you have a "gummy" smile (too much of your gums show when smiling)?

    Are your gums red, sore, puffy, bleeding or receded?

    Does the appearance of your smile inhibit you from laughing or smiling?

    When being photographed, do you smile with your lips closed instead of flashing a full smile?

    Are you self-conscious about your teeth or smile?

    Would you like to change anything about the appearance of your teeth or smile?

    If you answered YES to ANY of the questions above, there are often several alternatives to improve your teeth and smile. To receive a personalized response to your smile analysis, please complete the form below.

    You can have the smile you’ve always wanted! To schedule a no obligation office consultation, contact us today to schedule an appointment.

    Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.

    Book an Appointment

    Contact Us Today for All of Your Dental Care Needs!

    (613) 729-9933

    Dr. El Deeb Family Dental Care - Dentist Ottawa Ontario

    We are dedicated to providing high-quality dental care that looks after our patients’s oral health in the most warm, caring and respectful environment.

    Office Hours

    Monday: 8:00am - 5:00pm
    Tuesday: 8:00am - 5:00pm
    Wednesday: 8:00am - 5:00pm
    Thursday: 8:00am - 5:00pm
    Friday: 10:00am - 2:00pm
    Every 3rd Thursday of the month:
    10:00am - 7:00pm

    Contact Us


    1335 Carling Ave #106
    Ottawa, ON
    K1Z 8N8

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