skip to Main Content

(337) 704-2126 Schedule an Appointment 1601 Kaliste Saloom Rd, Lafayette LA 70508

<img width="240" height="35" src="https://maestridental.com/wp-content/uploads/2020/10/Logo_b0ff32d19d0c9c40f9fd9681a7d9f5c2.png" class="vc_single_image-img attachment-full" alt="Maestri Logo" title="Logo_b0ff32d19d0c9c40f9fd9681a7d9f5c2" />

home
about us
patient services
patient information
- Loyalty Dental Plan
blog
contact us
Search

Search

<img width="240" height="35" src="https://maestridental.com/wp-content/uploads/2020/10/Logo_b0ff32d19d0c9c40f9fd9681a7d9f5c2.png" class="vc_single_image-img attachment-full" alt="Maestri Logo" title="Logo_b0ff32d19d0c9c40f9fd9681a7d9f5c2" />

home
about us
patient services
patient information
- Loyalty Dental Plan
blog
contact us
Search

Search

SMILE & HEALTH EVALUATION FORM

we want you to love your smile!

Please fill out the form below. If you have trouble filling out this form online, please email beth@maestridental.com to send you a printable version of the form to fill out and bring with you to your next appointment.

* Required


                        First Name* 
Last Name* 
Email*
                            
                        
Do you like the overall appearance of your teeth, your smile?*
								
								Yes!
							

								
								No - chipping
							

								
								No - protruding
							

								
								No - artificial looking
							

								
								No - crowded/spacing
							

								
								No - excessively worn (short teeth)
							

								
								No - shape
							

								
								No - other
							
Do you like the color of your teeth?*
								
								Yes!
							

								
								No - coffee/tea stains
							

								
								No - tobacco stains
							

								
								No - discolored fillings
							

								
								No - tetracycline stains
							

								
								No - silver filling stains
							

								
								No - other
							
Do you consider your existing fillings or dental work to be attractive*
								
								Yes
							

								
								No
							

								
								N/A
							
Do you think your gums are attractive?*
								
								Yes!
							

								
								No - swollen
							

								
								No - reddened
							

								
								No - bleed easily
							

								
								No - Halitosis (bad breath)
							

								
								No - excessively receded
							

								
								No - crowns are ill-fitting
							

								
								No - difficult to clean between teeth
							

								
								No - other
							
When was your last dental visit?* 
How often do you see the dentist?* 
Have you had any dental issues that cause you discomfort? If yes, explain. If no, please leave N/A* 
Have you ever experienced any of the following problems with your jaw?*
								
								No
							

								
								Clicking
							

								
								Pain (joint, ear, face)
							

								
								Difficulty opening/closing
							
Do you have frequent headaches?*
								
								Yes
							

								
								No
							

								
								N/A
							
Do you clench or grind your teeth?*
								
								Yes
							

								
								No
							

								
								N/A
							
Have you ever had Botox for cosmetic purposes or for TMJ pain?*
								
								Yes
							

								
								No
							
Do you snore or have you ever been told you snore?*
								
								Yes
							

								
								No
							
CAPTCHA

Maestri icon

welcome

Welcome to exceptional family dentistry in Lafayette. Dr. Gina Liggio Maestri DDS and her team of dedicated dental professionals are here to provide you and your family with a level of caring clinical excellence you’ve never experienced before. From our state-of-the-art technology to our many comfort amenities, we have everything you need to feel relaxed while you enjoy gentle dentistry in Acadiana.

find us @

1601 Kaliste Saloom Rd
Lafayette, LA 70508

337-704-2126

SCHEDULE AN APPOINTMENT

Maestri icon

find us @

1601 Kaliste Saloom Road
Lafayette, LA 70508

337-704-2126

SCHEDULE AN APPOINTMENT

© Gina Liggio Maestri, DDS Family Dentistry 2019

Back To Top