Porcelain Veneer Application

Congratulations, You're almost there!

In order to best serve you there is a little bit of history we need to know about you BEFORE we get you on the schedule to meet with Dr. Austin!

Please complete this short questionnaire below and once you're done, we'll review your application to see if you're a good candidate for porcelain veneers and email you with the next steps.

Mobile Phone #

What are the primary problems you'd like to fix with your teeth?

Color

Shape

Length

Size

Arrangement/Position

Spacing

Crowding

How many teeth on the top do you feel needs improving with porcelain veneers?

How many teeth on the bottom do you feel needs improving with porcelain veneers?

What is the budget for your smile makeover?

$6000-$8000

$9000 - $12000

$12000-$16000

$15000 - $20000

$20000 +

Will you be paying cash or financing your smile?

Cash

Financing

Don't Know Yet

Would you like to see if you qualify for 12 months 0% interest payment plan or an extended payment plan for up to 5 years with one of our lending partners?

Yes

Have your teeth been professionally cleaned in the past 6 months?

Yes

Have you had a full set of X-rays of your whole mouth taken by your general dentist within the last 12 months?

Yes

If yes, would you be able to retrieve a digital copy to send to me for my review?

Yes

Do you have visible cavities in your teeth?

Yes

Are you missing any teeth?

Yes

Are your teeth loose?

Yes

How soon are you looking to change your smile with veneers?

Immediately

Within the next month

3 months

6 months

12 months

Is there anything else that you’d like our team to know?

We use cookies and other similar technologies to improve your browsing experience and the functionality of our site. By clicking "Accept All Cookies," you consent to the storing on your device of all the technologies described in our Cookie Policy. You can revoke your cookie attestation by clearing your browser session and clicking "Dismiss".