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Do you have concerns about? (please check all that apply)

Gaps or Spaces between Teeth
Color of Teeth
Shape of Teeth
Size of Teeth
Show too much Gum
Symmetry of Teeth
Position of Teeth (crooked or crowded)
Teeth Chipped or Broken
Discolored Restorations (i.e. existing crowns, fillings, bonding)
Front Teeth
Back Teeth
Inflamed or Bleeding Gums



What do you like best about your smile?

What do you like least about your smile?
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New Patient Offer

Receive $50.00 off any Cosmetic or Restorative Dental Procedure

Existing Patient Offer

$50.00 off ZOOM! One Hour Whitening 

Offers Expires:  03/21/2010

Complete the form below to take advantage of either of these offers.


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Eastgate Smiles Dental Care · 473 Old State Route 74 · Cincinnati, OH · 45244 · (513) 528-0788
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