Step 1

DENTURE
ASSESSMENT

We want to make sure that our dentures are the right fit for you. Please answer the following questions.

Do any of these statements apply to you?

I wear a fixed retainer or braces.
I have an issue with my teeth or gums that would affect the fit of the denture such as broken teeth, open wounds, or pain.
I have loose crown(s), loose veneer(s) or loose teeth.

If one or more of the above statements apply to you, Smile Wide does not recommend purchasing dentures. Please consult with a dental professional.

None of the above statement apply to me.

Smile Wide recommends a full dental examination by a dentist prior to having dentures. This ensures that your mouth is healthy and your teeth have no underlying issue that could interfere with a denture.

I’ve had a dental exam in the last 12 months and I can receive dentures.

I did not have a dental exam in the last 12 months and I’ve decided to go ahead with the making of dentures at my own risk.

Please note that Smile Wide may terminate its services at any time if your denture case is deemed too complex. If that happens, you will receive a full refund.

Unhealthy teeth may become loose with the wear of a denture. Any source of pain in your mouth should be investigated by a dentist.

I declare that I've understood the current document and the info I’ve provided is accurate

First Name

Last Name

Date of Birth

Initials

Enjoy your new smile!

Step 1

DENTURE ASSESSMENT

DENTURE
ASSESSMENT